Baylor Institute for Rehabilitation

Outpatient Service Injury Report

Referral Hotline - 888-7BAYLOR / Fax (717) 412-9175

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Event & Injury Information
Event (required)	You must enter an event name.
Date (MM/DD/YYYY; required)	You must enter an event date. You must enter an event date.
Location
Referral Location
Athlete's Name (required)	You must enter the athlete's name.
Athlete's Gender	Male Female
Date of Birth (MM/DD/YYYY)	Invalid date of birth.
Organization/Team
Jersey #
Parent/Guardian
Parent/Guardian Phone # (required)	You must enter the parent/guardian phone #.
Address
City, State
Zip Code
Responding Athletic Trainer (required)	You must enter your name.
Injury History
Injured Area
Time of Injury (HH:MM AM/PM)
Mechanism
Examination
Subjective
Objective
Assessment
Plan
Notes
Security Challenge