Injury Evaluation Form

Name

Date

Age

Involved Body Part

Right or Left?

Right

Left

Both

Is one worse than the other?

Right Worse

Left Worse

Describe what happened (i.e. got hit, twisted skiing, over time)

If injured, did you feel/hear a pop?

Yes

No

Did it swell?

Yes

No

When did it swell?

Immediately

Over Several Hours

Next Day

Does it swell now?

Yes

No

If not injured, what activity do you think caused/contributed to the problem?

Do you have any of the following? (CTRL+Click for multiple selection)

Pain is located on?

What makes pain worse? (CTRL+Click for multiple selection)

What makes pain better? (CTRL+Click for multiple selection)

How severe is the pain on average? (none) 0 1 2 3 4 5 6 7 8 9 10 (extreme)

Medications taken for this? (CTRL+Click for multiple selection)

If you selected "Other" from item above, please list any other medication here.

Injections? (CTRL+Click for multiple selection)

Please list dates of injections:

Percent improvement with injection(s)

Previous treatment for this problem:

Previous Surgery (Date and Surgeon)

Previous injuries to this body part/date(s)

Tests you have had for this condition? (CTRL+Click for multiple selection)

If selected "Other" above, please explain.

Sports/recreational activities

Level of sport currently: (CTRL+Click for multiple selection)

Occupation

Current School and Grade Level

Goals after treatment for this problem

Injury Evaluation Form

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