JCF Initial Injury Report

JCF Initial Injury Report

We hear you're injured! Let us know what happened and answer some questions about how we can help you get healthy again!
  • Describe by name of specific injury, or if you are unsure describe where on body injury is located.
  • Describe where, when and how the injury occured to the best of your ability.
  • Please enter a value between 1 and 10.
    1-3 = mild pain (annoying, interferes little with daily activities) 4-6 = moderate pain (interferes significantly with daily activities) 7-10 = severe pain (disabling; unable to perform daily activities)
  • Select one
  • Select one
  • If you have seen a medical professional please explain your diagnosis, otherwise answer n/a
  • Select one
  • If not applicable type n/a
  • if not applicable answer n/a
  • if not applicable please answer n/a