Return to Sport Evaluation Form
Complete this assessment to help determine if the athlete is ready to return to sport participation after injury or time away.
Athlete Full Name
*
First Name
Last Name
Sport/Activity
*
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Symptoms
*
No symptoms
Mild symptoms
Moderate symptoms
Severe symptoms
Pain Level During Activity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Functional Movements Assessment
*
Rows
Unable
Difficult
Normal
Running
1
2
3
Jumping
4
5
6
Cutting/Pivoting
7
8
9
Sport-specific skills
10
11
12
Confidence in Returning to Sport
*
1
2
3
4
5
Has the athlete completed the recommended rehabilitation program?
*
Yes
No
In progress
Is the athlete cleared to return to sport?
*
Yes
No
With restrictions
Additional Comments or Follow-up Recommendations
Submit Evaluation
Should be Empty: