Swink Injury Report

Swink Sports Injury Report

NOTE: Coaches without medical training should refer all medical decisions to appropriately qualified persons. Do not attempt to 'diagnose' an injury. Users of this form are advised that medical information should be treated confidentially. In some states, additional legislation affects the management of health records.
Injury details: This report reflects an accurate record of the injured person's reported symptoms of injury
DATE WHEN INJURY OCCURRED: *

Month Day Year
Date
PERSON INJURED *

ATHLETE STUDENT COACH PARENT
NAME OF PERSON INJURED: *
DATE OF BIRTH: *

Month Day Year
Date
GENDER: *

MALE FEMALE
SUPERVISOR/EVENT SUPERVISOR: *
WITNESS: *
FIRST AID PROVIDED BY: *
Time of first aid *

: Hour Minutes AM/PM Option
NATURE OF INJURY: *

NEW INJURY RECURRENT INJURY AGGRAVATED INJURY
INJURY OCCURRED DURING... *
HOW DID THE INJURY OCCUR? *
COLLISION WITH FIXED OBJECT OVERBALANCE COLLISION/CONTACT WITH ANOTHE PERSON OVERSTRETCH FALL FROM HEIGHT/AWKWARD LANDING SLIP/TRIP FALL/STUMBLE ON SAME LEVEL
WAS PROTECTIVE EQUIPMENT WORN ON THE INJURED BODY PART? *

YES NO NOT NEEDED
SYMPTOMS OF INJURY (IF STUDENT/ATHLETE, PLEASE NOTIFY THE AD) *

BLISTERS BLEEDING NOSE BRUISING/CONTUSION CUT GRAZE/ABRASION SPRAIN STRAIN INFLAMMATION/SWELLING CRAMP SUSPECTED BONE FRACTURE/BREAK DISLOCATION CONCUSSION/HEAD INJURY LOSS OF CONSCIOUSNESS RESPIRATORY PROBLEM SPINAL INJURY CARDIAC PROBLEM ELECTRICAL SHOCK BURN INSECT BITE/STING POISONING
INITIAL TREATMENT *

NO TREATMENT REQUIRED CPR CRUTCHES DRESSING MASSAGE RICER SLING/SPLINT STRAPPING STRETCHING
FOLLOW UP

NOTE: Coaches without medical training should refer all medical decisions to appropriately qualified persons. Do not attempt to 'diagnose' an injury. Users of this form are advised that medical information should be treated confidentially. In some states, additional legislation affects the management of health records.
FOLLOW UP ACTION *

NONE MEDICAL/PRACTITIONER/PHYSIOTHERAPIST HOSPITAL AMBULANCE IMPACT POST TEST
FOLLOW UP NOTES *
TODAY'S DATE *

Month Day Year
Date
NAME OF PERSON COMPLETING FORM: *
Signature of person completing form *

Clear
Should be Empty:

Swink Sports Injury Report

FOLLOW UP