Injured Athlete Self-Assessment Form
Athletes: Please complete this form to self-report an injury and assess your current condition.
Full Name
*
First Name
Last Name
Date of Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Activity When Injury Occurred
*
Please Select
Training
Competition
Recreational
Other
Injury Location
*
Please Select
Head/Neck
Shoulder/Arm
Back
Hip/Groin
Knee
Ankle/Foot
Other
How would you rate your pain or discomfort right now?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible
10
0 is No pain, 10 is Worst possible
How severe do you feel your injury is?
*
Mild
Moderate
Severe
Are you able to continue participating in your sport or activity?
*
Yes, without limitation
Yes, but with limitation
No
Please rate the impact of your injury on the following activities:
*
Rows
No impact
Mild impact
Moderate impact
Severe impact
Walking
1
2
3
4
Running
5
6
7
8
Climbing stairs
9
10
11
12
Sleeping
13
14
15
16
Daily activities
17
18
19
20
Have you experienced any of the following symptoms since your injury?
*
Swelling
Bruising
Limited range of motion
Weakness
None of the above
Other
Briefly describe how the injury occurred and any additional information:
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