ISU Medical Form - International Skating Union

Please report all injuries (go to Part I) and all illnesses (go to Part II)

One Form must be completed by the Skater's Medical Staff or Chief Medical Officer for each injured or ill Skater.
Any copies of conducted laboratory, radiological or medical examination for the injury/illness are to be sent to by separate E-mail at medical@isu.ch

Reason: (*)

Withdrawal from ISU EventReporting Injury Invalid Input

Name of the Event:(*)

Please type your full name.

Location: (*)

Invalid Input

Discipline:(*)

Athlete's First Name: (*)

Invalid Input

Athlete's Last Name: (*)

Invalid Input

Athlete Nationality:(*)

Age:(*)

Invalid Input

Gender:(*)

Male Female Invalid Input

I. INJURY

Diagnostic impression:(*)

Invalid Input

Date of Injury: (*)

Invalid Input

Characteristics of injury:

Acute (new onset) Recurrent (upon previous injury) Chronic Invalid Input

Circumstances:

Practice/Training Competition Other (specify) Invalid Input

Other:

Invalid Input

Body Part:

Type of Injury:

Other:

Invalid Input

Cause:

Contact with person Contact with equipment Contact with Boards/Pads Contact with Ice Non-contact injury Invalid Input

Injury Severity:

Resumed activity Unable to train/compete Transport to hospital Invalid Input

Expected absence:

Less than 1 day 1 to 3 days 4 to 7 days Greater than 7 days Invalid Input

II. ILLNESS

Main Symptom(s):

Other symptoms:

Invalid Input

Affected Systems:

Other:

Invalid Input

Supposed cause of illness:

TREATMENT

Treatment Modalities:(*)

Other treatment:

Invalid Input

Medication #1:

Invalid Input

Medication #2:

Invalid Input

Medication #3:

Invalid Input

Medication #4:

Invalid Input

Full Name:(*)

Invalid Input

Function/Title:(*)

Invalid Input

(Other):(*)

Invalid Input

E-mail(*)

Invalid Input

Terms and Conditions(*)

I declare that these information are correct Invalid Input

Security(*)

Invalid Input

July 2019 - Medical Information Package (#9)