injury report Date * MM DD YYYY Time * Hour Minute Second AM PM Name * First Name Last Name Phone * (###) ### #### Email * Gender * Male Female Other Injury Description * Cut Bruise Burn Epistaxis Graze Fracture Sprain Athsma Fainting Bite/Sting Other Specify (If other) Size of Injury * Under 5cm Over 5cm N/A Cause of Injury * Slip/Fall Collision Insect Other animal Heat Cold Other Specify (If other) Location of Injury (1) * Head Nose Mouth Ear Eye Elbow Upper Arm Lower Arm Hand Finger/s Upper Leg Lower Leg Knee Ankle Foot/Feet Toe/s Other Specify (If other) Location of Injury (2) * Right Left Front Back Upper Lower Other Specify (If other) First Aid * Bandaid Steri-Strip Bandage Gauze Immobilisation Ice Pressure Other Specify (If other) Ambulance Called * YES NO Further Medical Treatment Advised * YES Immediate YES at own discretion NO Thank you!
