I I Club or High School I week in gym HeightWeight of years gymnastics Current Injury and brief history of how it happened Is this a rein jury D Yes D Questionnaire Plea ID: 895037
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1 Personal History Today's Date: __ / __ /
Personal History Today's Date: __ / __ / __ _ Name: Date of Birth: I I ----------------------Club or High School I week in gym: ___ Height/Weight: ____ _____:/ ___ _ #of years gymnastics:____ _ Current Injury and brief history of how it happened: ____________ _ Is this a rein jury? D Yes D _ Questionnaire Please list all injuries that have held you out of gymnastics for Please list all orthopedic surgeries (bone or joint only): ___________ _ For your current injury, what skills or movemen
2 ts are the most painful? Check all. Oth
ts are the most painful? Check all. Other: ______ _ Do you wear braces when doing Paws (floor/vault) D Ankle braces D Knee braces Have you done Physical Therapy Office Use Only Imaging: Skeletal Maturity: D Yes DNo 0 Powerful 0 Graceful Ligamentous Laxity Scale: Diagnosis: Recommended Treatment: 0 No participation DMRI 0 Casting 0 Modified Activities -----------0 CT Scan D Therapy D Full as tolerated 0 Bracing: _____ _ D Other: -------Overall time loss for injury: _____________________