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! 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?*Before workoutDuring workoutAfter workoutAt restSelect oneSince injury first occurred has it gotten better, worse, or stayed the same?It has gotten betterIt has gotten worseIt has stayed the sameSelect 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/aHave you seen a physical therapist to rehab the injury?*Yes I am in rehabNo I am not in rehabNot yet but plan toSelect onePlease 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