USA Swimming ID
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Format: mmddyyFIRMLAST (Date of birth First three letters of first name Middle initial and First 4 letters of last name. Example: John W. Smith 12/25/1999 = 122599johwsmit
Date of Birth
* must provide value
Today M-D-Y
years
Male Female
3'6" 3'7" 3'8" 3'9" 3'10" 3'11" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5' 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6' 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11"
Feet (') and inches(")
lbs
Ensures questionnaire is only filled out once.
Freestyle Backstroke Breaststroke Butterfly Individual Medley
25 yards or meters 50 yards or meters 100 yards or meters 200 yards or meters 400 yards or meters 500 yards or meters 1000 meters 1650 yards
Number of years in competitive swimming?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 greater than 25
Months per year that you swim?
1 2 3 4 5 6 7 8 9 10 11 12
Days per week that you swim?
1 2 3 4 5 6 7
Average daily training distance while in season?
Under 2000 yards or meters 2000-3000 yards or meters 3000-4000 yards or meters 4000-5000 yards or meters 5000-6000 yards or meters 6000-7000 yards or meters 7000-8000 yards or meters 8000 or more yards or meters
Swim training methods used?
Check all that apply
Weight training methods used?
Check all that apply
Cross training methods used?
Check all that apply
Other training methods used?
Is the weight training or cross training conducted by your swim team?
Yes
No
Additional sports played?
Check all that apply
Have you every had an injury from swim training in the pool?
Yes
No
Example: Shoulder pain, knee pain, back pain
At what age did you get injured?
What body part was injured?
Neck Shoulder Elbow Wrist Hand Finger Back Groin Hip Knee Ankle Foot Toe Concussion
Classify pain related to the injury
No pain Pain only after heavy workouts Pain during and after workouts Pain interfering with performance Pain preventing competitive swimming
Impact of pain on training?
1 - None 2 - Mild 3 - Moderate 4 - Severe
How much time was missed from training/competition?
a. None b. Less than 1 week c. Between 1 week and 1 month d. More than 1 month
Who did you see about the injury?
Check all that apply
How was the injury treated?
Check all that apply
Was training regimen at time of injury the same as current training regimen previously described?
Yes
No
Months per year that you were swimming at time of injury?
1 2 3 4 5 6 7 8 9 10 11 12
Days per week that you were swimming at time of injury?
1 2 3 4 5 6 7
Average daily training distance at time of injury?
Under 2000 yards or meters 2000-3000 yards or meters 3000-4000 yards or meters 4000-5000 yards or meters 5000-6000 yards or meters 6000-7000 yards or meters 7000-8000 yards or meters 8000 or more yards or meters
Swim training methods used at time of injury?
Check all that apply
Weight training methods used at time of injury?
Check all that apply
Cross training methods used at time of injury?
Check all that apply
Other training methods used at time of injury?
Weight training or cross training conducted by your swim team at time of injury?
Yes
No
Additional sports played at time of injury?
Check all that apply
Did you ever have another injury from swim training?
Yes
No
At what age did you get injured?
What body part was injured?
Neck Shoulder Elbow Wrist Hand Finger Back Groin Hip Knee Ankle Foot Toe Concussion
Classify pain related to the injury
1 - No pain 2 - Pain only after heavy workouts 3 - Pain during and after workouts 4 - Pain interfering with performance 5 - Pain preventing competitive swimming
Impact of pain on training?
1 - None 2 - Mild 3 - Moderate 4 - Severe
How much time was missed from training/competition?
a. None b. Less than 1 week c. Between 1 week and 1 month d. More than 1 month
Who did you see about the injury?
Check all that apply
How was the injury treated?
Check all that apply
Was training regimen at time of injury the same as current regimen previously described?
Yes
No
Months per year that you were swimming at time of injury?
1 2 3 4 5 6 7 8 9 10 11 12
Days per week that you were swimming at time of injury?
1 2 3 4 5 6 7
Average daily training distance at time of injury?
Under 2000 yards or meters 2000-3000 yards or meters 3000-4000 yards or meters 4000-5000 yards or meters 5000-6000 yards or meters 6000-7000 yards or meters 7000-8000 yards or meters 8000 or more yards or meters
Swim training methods used at time of injury?
Check all that apply
Weight training methods used at time of injury?
Check all that apply
Cross training methods used at time of injury?
Check all that apply
Other training methods used at time of injury?
Weight training or cross training conducted by your swim team at time of injury?
Yes
No
Additional sports played at time of injury?
Check all that apply
If you have had more than 2 injuries from swimming please select the total number of injuries
3 4 5 6 7 8 9 10 more than 10
Have you ever had an injury out of the pool while training for swimming? (i.e. cross training, weight lifting)
Yes
No
Activity during which the injury occurred?
Running Running stairs Free weight lifting Kettle bell lifting Body weight exercises (push ups, pull ups, dips) Circuit training Cross Fit Yoga Jumping rope Other
At what age did you get injured?
What body part was injured?
Neck Shoulder Elbow Wrist Hand Finger Back Groin Hip Knee Ankle Foot Toe Concussion
Classify pain related to the injury
1 - No pain 2 - Pain only after heavy workouts 3 - Pain during and after workouts 4 - Pain interfering with performance 5 - Pain preventing competitive swimming
Impact of pain on training?
1 - None 2 - Mild 3 - Moderate 4 - Severe
How much time was missed from training/competition?
a. None b. Less than 1 week c. Between 1 week and 1 month d. More than 1 month
Who did you see about the injury?
Check all that apply
How was the injury treated?
Check all that apply
Was training regimen at time of injury the same as previously described?
Yes
No
Months per year that you were swimming at time of injury?
1 2 3 4 5 6 7 8 9 10 11 12
Days per week that you were swimming at time of injury?
1 2 3 4 5 6 7
Average daily training distance at time of injury?
Under 2000 yards or meters 2000-3000 yards or meters 3000-4000 yards or meters 4000-5000 yards or meters 5000-6000 yards or meters 6000-7000 yards or meters 7000-8000 yards or meters 8000 or more yards or meters
Swim training methods used at time of injury?
Check all that apply
Weight training methods used at time of injury?
Check all that apply
Cross training methods used at time of injury?
Check all that apply
Other training methods used at time of injury?
Weight training or cross training conducted by your swim team at time of injury?
Yes
No
Additional sports played at time of injury?
Check all that apply
Have you ever had another injury while training out of the pool?
Yes
No
Activity during which the injury occurred?
Running Running stairs Free weight lifting Kettle bell lifting Body weight exercises (push ups, pull ups, dips) Circuit training Cross Fit Yoga Jumping rope Other
At what age did you get injured?
What body part was injured?
Neck Shoulder Elbow Wrist Hand Finger Back Groin Hip Knee Ankle Foot Toe Concussion
Classify pain related to the injury
1 - No pain 2 - Pain only after heavy workouts 3 - Pain during and after workouts 4 - Pain interfering with performance 5 - Pain preventing competitive swimming
Impact of pain on training?
1 - None 2 - Mild 3 - Moderate 4 - Severe
How much time was missed from training/competition?
a. None b. Less than 1 week c. Between 1 week and 1 month d. More than 1 month
Who did you see about the injury?
Check all that apply
How was the injury treated?
Check all that apply
Was training regimen at time of injury the same as previously described?
Yes
No
Months per year that you were swimming at time of injury?
1 2 3 4 5 6 7 8 9 10 11 12
Days per week that you were swimming at time of injury?
1 2 3 4 5 6 7
Average daily training distance at time of injury?
Under 2000 yards or meters 2000-3000 yards or meters 3000-4000 yards or meters 4000-5000 yards or meters 5000-6000 yards or meters 6000-7000 yards or meters 7000-8000 yards or meters 8000 or more yards or meters
Swim training methods used at time of injury?
Check all that apply
Weight training methods used at time of injury?
Check all that apply
Cross training methods used at time of injury?
Check all that apply
Other training methods used at time of injury?
Weight training or cross training conducted by your swim team at time of injury?
Yes
No
Additional sports played at time of injury?
Check all that apply
If you have had more than 2 injuries from training out of the pool please select the total number of injuries.
3 4 5 6 7 8 9 10 more than 10
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