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Injury Report Form
If a medical stuff treat a player, please fill in and send this form.
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* Required
Family name of player 受傷者の姓
*
Your answer
Given name of player 受傷者の名前
*
Your answer
Gender of player 性別
*
Man
Woman
Required
Age of player 年齢
*
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Other:
Required
Body weight (kg) 体重
<20kg
>20kg
>30kg
>40kg
>50kg
>60kg
Category of player 受傷者のカテゴリー
*
Super Ninjya
Ninjya
Shuriken
Junior Samurai
Samurai
Shogun
Colts(U18)
Coach
Staff
Required
Date of injury 受傷日
*
MM
/
DD
/
YYYY
Weather 天気
*
Sunny
Cloudy
Rain
Other:
Required
Place 受傷したグラウンド
*
Showa / South
Showa / Leo
Showa / Primary School
Nagasawa
Other:
Required
Body Part of injury 受傷部位
*
Head or Forehead 頭もしくは額
Eye 目
Nose 鼻
Ear 耳
Lips 唇
Tooth 歯
Other part of face 顔の上記以外の部分
Neck 首
Ribs 肋骨
Abdomen 腹部
Other part of spine and trunk 体幹と脊椎の上記以外の部分
Clavicle 鎖骨
Shoulder 肩
Upper Arm 上腕
Elbow 肘
Forearm 前腕
Wrist 手関節
Hand 手
Fingers 指
Other part of upper extremity 上肢の上記以外の部分
Hip 股関節
Thigh 大腿
Knee 膝
Lower Leg 下腿
Achilles Tendon アキレス腱
Ankle 足関節
Foot 足部
Toes 足趾
Other part of lower extremity 下肢の上記以外の部分
Heatstroke 熱中症
Other:
Required
Type of injury 受傷形態
*
Concussion 脳震盪
Bleeding/Hemorrhage 出血
Contusion 打撲
Bone Injury 骨折
Joint Injury 関節損傷（捻挫、靱帯損傷）
Muscle Injury 筋損傷
Skin Injury 皮膚損傷
Dental Injury 歯口腔内損傷
Other:
Mechanism of injury 受傷機転
*
Contact 接触
Non-contact 非接触
Overuse オーバーユース
Recurrent Injury 再受傷
Other:
Severity of Injury 重症度
*
Mild (treated at the site) 処置後プレイ継続
Mild--Moderate (treated at the site and play terminated without further follow up at a clinic) プレイ中止したが受診なし
Severe-Moderate (treated at the site and play terminated with further follow up at a clinic) プレイ中止し受診あり
Sever (Call 119) 救急搬送
Other:
Required
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