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Tahquitz Sports Medicine
Online Injury Reporting
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* Indicates required question
Email
*
Your email
Athletes Name
*
Your answer
Athletes Student ID Number
*
Your answer
Date of Injury
*
MM
/
DD
/
YYYY
Person Reporting Injury
*
Choose
Self
Parent of Athlete
Athletes Coach
Teacher / Staff
Sport and Level (FRESH, JV, VAR)
*
Your answer
Injured Area
*
Choose
Head
Face
Neck
Shoulder
Upper Arm
Elbow
Lower Arm or Wrist
Hands or Fingers
Chest or Upper Torso
Lower Torso or Abdominal
Upper Back or Middle Back
Lower Back
Hips
Upper Leg
Knee
Lower Leg
Ankle
Foot or Toes
Briefly describe your injury. Rate pain 1-10, 10 being the worst pain imaginable.
*
Your answer
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