Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Male
Female
Role
*
Player
Umpire
Official
Spectator
Club
*
Age Level
*
Please Select
Auskick & Junior Football
Under 18 & Seniors
Junior Team
*
Please Select
Auskick
Under 8.1
Under 8.2
Under 9.1
Under 9.2
Under 10.1
Under 10.2
Under 10 Girls
Under 12.1
Under 12.2
Under 12.3
Under 12 Girls
Under 14.1
Under 14.2
Under 14.3
Under 14 Girls
Under 16.1
Under 16.2
Under 16.3
Under 16 Girls
Senior Team
*
Please Select
Under 18.1
Under 18.2
Under 18 Women
Thirds
Reserves
Seniors
Netball
Venue
*
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Injury Information
Date of Injury
*
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of activity at time of injury
*
training/practice
competition
Other
Reason for Presentation
*
new injury
exacerbated/aggravated injury
recurrent injury
illness
Other
Was there a Head Knock?
*
Yes
No
Possible
Body Region Injured
*
Body part/s
Nature of Injury/Illness
*
abrasion/graze
open wound/laceration/cut
bruise/contusion
inflammation/swelling
fracture (inc suspected)
dislocation/subluxation
sprain (eg ligament tear)
strain (eg muscle tear)
overuse injury to muscle or tendon
blisters
concussion
cardiac problem
respiratory problem
loss of conscioussness
unspecified medical condition
Other
Provisional diagnosis
*
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Cause of Injury
Mechanism of Injury
*
struck by other player
struck by ball (eg dislocated finger)
collision with other player/umpire
collision with fixed object (eg goal post)
fall/stumble on same level
jumping
landing from jump
slip/trip
twisting to pass or accelerate
overexertion (eg muscle tear)
temperature related (eg heat stress)
Other
Explain exactly how the incident occurred
*
Where there any contributing factors to the incident, unsuitable footwear, playing surface, equipment, foul play?
*
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Protective Equipment
Was protective equipment worn on the injured body part?
*
Yes
No
If yes, what type (eg mouthguard, ankle brace, taping)
*
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Treatment Information
Initial Treatment
*
none given (note required)
RICER
sling, splint
massage
CPR
strapping/taping only
dressing
crutches
manual therapy
stretch/exercise
none given (referred elsewhere)
Other
Advice Given
*
immediate return unrestricted activity
able to return with restriction
unable to return at present time
Referral
*
no referral
medical practitioner
physiotherapist
chiropractor or other professional
ambulance transport
hospital
Other
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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Concussion Information
Was a Concussion Assessment conducted?
*
Yes
No
Is there a suspected concussion?
*
Yes
No
Was the player/guardian advised they require a concussion assessment/ clearance from a Medical Practioner?
*
Yes
No
AFL Medical Clearance Form
Form Available Here
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Additional Information
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: 0000 000 000.
Emergency Contact Email
example@example.com
Patient Contact Number
Please enter a valid phone number.
Format: 0000 000 000.
Patient Contact Email
example@example.com
Any Additional Information
File Upload
Browse Files
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Choose a file
Any supporting documents or photos
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Treating Person
Treating Person Name
*
First Name
Last Name
Treating Person Club
*
Treating Person Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Treating Person Email
*
example@example.com
Treating Person Role
*
sports trainer
medical practitioner
physiotherapist
nurse
Other
Any notes
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
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