Date
-
Day
-
Month
Year
Date
Time
Hour Minutes
Critical Incident
Yes
No
If yes, who is involved
Police
Coroner
N/A, referral
Referral
No referral
Medical practitioner
Physiotherapist
Ambulance transport
Hospital (private car)
Helicopter
Other
Referred to (Name)
Transported to by
Private Car
Ambulance
Helicopter
Treating person
Medical Practioner
First Aid Provider
Other
Event details
EVENT
Permit Number
Discipline
Please Select
Motorcross/Supercross
Road Race
Enduro
Trials
Trails
Dirt Track
Speedway
ATV
Supermoto
Minikana
Promoter
Type of activity at time of injury
Practice
Competition
Recreational (RPA)
Other
Venue
Person
Competitor
Spectator
Official
Other
Class
Bike Number
Location/ Turn number
Racing Stopped
Yes
No
Arrived at Medical Centre by
Walk In
FIV
Ambulance
Other
Injuries
Yes
No
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Patient Details
Patient Name
First Name
Last Name
MA Licence Number
Date of birth
-
Day
-
Month
Year
Date
Address
Phone Number
Please enter a valid phone number.
Emergency Contact Name
Emergency Contact Number
Please enter a valid phone number.
Medical Background
Concurrent Illnesses and Previous Operations
Tetanus (Up to date)
Yes
No
Current Medication
Allergies
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BP
GCS
Heart Rate
SpO2 %
Relevant Presentation/ Examination/ Treatment Details
Summary of injuries
Medical Clearance Required
Yes
No
Marks/ Impact to Helmet
Draw on Image
Helmet Pictures
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Nature off Injury/illness
Abrasion/graze
Sprain e.g. ligament tear
Strain e.g muscle tear
Open wound/laceration/cut
Bruise/contusion
Inflammation/swelling
Dislocation/subluxation
Overuse injury to muscle or tendon
Blisters
Fracture (Including suspected)
Concussion
Cardiac problem
Respiratory problem
Loss of consciousness
Unspecified medical condition
Other
Body Region Injured (Tick or circle body part/s injured)
Protective Equipment
Was protective clothing worn on the body injured body part?
Yes
No
If yes, what type eg helmet, neck brace
Reason for Presentation
New Injury
Exacerbated/aggravated injury
Recurrent injury
Illness
Other
Mechanism of Injury
High side
Low side
Impact
Hit wall/ Barrier/ Object
Overexertion (eg. Muscle tear)
Overuse
Slip/Trip
Temperature related eg. Heat Stress
Jump
High Speed
Medium Speed
Low speed
Other
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Initial Treatment
None given, not required
RICER (rest, ice, compression, elevation, referral)
Taping only
Sling, splint
CPR
Dressing
Crutches
Stretch/ exercises
None given - referred elsewhere
Other
Advice Given
Immediate return, unrestricted activity
Able to return with restriction
Unable to return at the present time
Rider able to return but chose not to
Referred for further assessment before returning to activity
Provisional Severity assessment
Mild (1-7 days, modified activity)
Moderate (8-21 days modified activity)
Severe (>21 days modified or lost)
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Form Completed by
Name of Medical Service Provider
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Role
Time
Hour Minutes
Signature
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