International School of Port of Spain

RETURN TO PLAY FORM

Name of Injured Athlete: ______________________Grade: ______ Age: _____

Sport Participating In: _____________________ Position: _________________

DETAILS OF INJURY: _____________________________________________

                                      ______________________________________________

                                      ______________________________________________

Date of Injury: ______________________________ Time: _________________

Injured During: Practice: _______ Game: ________ Other: _________________

Mechanism of Injury: _______________________________________________

TO BE COMPLETED BY PHYSICIAN

Impression/Diagnosis: ______________________________________________

Recommendations: _________________________________________________

                             __________________________________________________

                             __________________________________________________

No Restrictions (discharged) as of: _____________________________________

No Practice or Play until: ____________________________________________

Expected Return to Activity (definite date upon further evaluation) ___________

Other: ____________________________________________________________