Instructions
ID # (this number can be found on your weekly email)
First Name (for identification conformation)
Date of injury MM-DD-YYYY
-
1. When did the injury occur?
Practice
Game
Tournament
2. Was the injury?
New Injury
Previous injury from ultimate
Previous injury from other
3. What position were you playing when injured?
Offense-throwing
Offense-catching
Defensive-throwing
Defensive-catching
4. Site of injury? (please check all that apply)
Head
Face
Neck
Shoulder
Upper arm
Lower arm
Wrist
Hand
Fingers
Abdomen
Back
Pelvis
Upper leg
Lower leg
Knee
Ankle
Foot
Toes
5. Severity of injury?
Minor - if able to return to training/game in which injury occured
Mild - if missed one week
Moderate - if missed two weeks
Severe - if missed more than 2 weeks
6. What is the primary cause of the injury?
Field Conditions
Team Size
Fitness level
Improper warm-up
Clothing (uniform, shoes)
Equipment (disc, marker, cone)
Diving for disc
Collision with another player
Tournament organization
7. Was weather a factor?
No
Hot
Wet
Cold
8. Was the play you were injured on?
Legal
Illegal
9. What was the most serious injury?
Muscle Strain
Ligament (joint) sprain
Abrasion/scratch/bruise
Broken bone
Concussion
10. Who evaluated the injury? (please check all that apply)
Self
Coach
Teammate/fellow player
Athletic trainer
Physical therapist
Message therapist
Family doctor
Emergency room
Chiropractor
11. What treatments were used? (please check all that apply)
No treatment
Surgery
Ice
Heat
Prescription Medication
Cast/brace
Over The Counter Medication
Massage
12. What can be done to prevent future injuries like you experienced?
