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!

Name*
First Last
Phone*
What is injured?*
Describe by name of specific injury, or if you are unsure describe where on body injury is located.
How and when did the injury occur?*
Describe where, when and how the injury occured to the best of your ability.
Describe pain on a scale of 1-10*
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)
When do you feel the most pain?*
Select one
Since injury first occurred has it gotten better, worse, or stayed the same?
Select one
Have you seen a doctor to diagnose the injury? If yes, what is your diagnosis?*
If you have seen a medical professional please explain your diagnosis, otherwise answer n/a
Have you seen a physical therapist to rehab the injury?*
Select one
Please share any movements your doctor and/or PT recommended that you perform and those which you should avoid.*
If not applicable type n/a
Please share the name and contact info of your doctor and/or PT*
if not applicable answer n/a
If you have been advised not to workout at JCF, when is your estimated return date?*
if not applicable please answer n/a