AUSTRALIAN FOOTBALL INJURY REPORTING FORM

Name: _________________________________ Initials: _____ Position: _______________________ Circle Player/Umpire/Coach/Spectator

Team :_________________________ Grade: ___________ DOB: __/__/__ Gender: M F Venue/area at which injury occurred: ____________________

Date of Injury __/__/__ Nature of Injury/Illness Explain exactly how the incident occurred Advice Given
† abrasion/graze _________________________________ † immediate return unrestricted activity
Type of activity at time of injury open wound/laceration/cut _________________________________ † able to return with restriction
training/practice † bruise/contusion __________________________________ unable to return at present time
competition † inflammation/swelling __________________________________
other _________________________ † fracture (including suspected) __________________________________ Referral
† dislocation/subluxation __________________________________ † no referral
Reason for Presentation sprain eg ligament tear __________________________________ medical practitioner
† new injury strain eg muscle tear __________________________________ physiotherapist
† exacerbated/aggravated injury † overuse injury to muscle or tendon __________________________________ chiropractor or other professional
recurrent injury blisters __________________________ ambulance transport
illness concussion hospital
† other __________________________ cardiac problem Were there any contributing factors to the other __________________________
respiratory problem incident, unsuitable footwear, playing
Body Region Injured loss of consciousness surface, equipment, foul play? Provisional severity assessment
Tick or circle body part/s injured & name unspecified medical condition __________________________________ † mild (1-7 days modified activity)
other __________________________ __________________________________ † moderate (8-21 days modified activity)
_______________________________ † severe (>21 days modified or lost)
Provisional diagnosis/es _____________
_________________________________ Protective Equipment Treating person
_________________________________ Was protective equipment worn on the medical practitioner
injured body part? yes no physiotherapist
CAUSE OF INJURY † nurse
Mechanism of Injury If yes, what type eg mouthguard, ankle † sports trainer
† struck by other player brace, taping. † other __________________________
struck by ball (eg dislocated finger) _________________________________
collision with other player/referee Signature of treating person
collision with fixed object (goal post) Initial Treatment __________________________________
† fall/stumble on same level † none given (not required) ________________________________
† jumping RICER dressing
† landing from jump † sling, splint crutches Today’s Date: __/__/__
slip/trip massage manual therapy
Body part/s † twisting to pass or accelerate CPR stretch/exercises
_________________________________ overexertion (eg muscle tear) strapping/taping only
overuse † none given - referred elsewhere
_________________________________ † temperature related eg heat stress other __________________________
† other _________________________