Fairview Cross Country Suspected Injury Report

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PLEASE NOTE: This report is for athletes dealing with something beyond the normal aches and pains of an impact related sport. Athletes must check in at practice even if dealing with a possible injury. Do not go to the training room first. Notify your coach that you have submitted a form, and a cross training plan will be developed.

Athlete First Name *

Athlete Last Name *

Athlete Email

Today's Date *

YYYY

Athlete Grade Level *

Freshman

Sophomore

Junior

Senior

Nature of Complaint *

Hip

Knee

Lower Leg

Hamstring

Achilles

Foot/Ankle

Other:

Check the following that apply: *

I cannot give hard effort without pain.

I cannot give easy effort without pain.

Required

Describe your injury in detail. *

Current Status *

I've seen the trainer.

I've seen a doctor.

I've scheduled an appointment.

I'm icing daily.

I'm taking anti-inflammitories.

I need new shoes.

Other:

Required

Doctor/Therapist's Recommendation - Please include when you are cleared to return to workouts, if applicable.

Recovery Plan *

I'm requesting a reduced workout.

I'm requesting cross training.

I'm requesting a rest day.

I'm requesting a conference with a coach.

I plan to compete in the next meet.

I do not plan to compete in the next meet.

Required

Please include any other requests or information here.

Submit

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