Provider Visit Form

Provider’s Visit Form

Thank you for downloading the Provider’s Visit Form. We’re also excited you’ve decided to join us at Gymnast Care and be a part of our team.

Below, we go over each box in this form.

Being a gymnast’s parent is very hard work and it can become overwhelming at times. Then, to add to this, your gymnast becomes injured…What do you do next?

If it’s a simple issue, you can find many “at home” and “in the gym” solutions in the Gymnast Care Book on Injuries. If you haven’t yet had a chance to check out the incredible information found in this book, we have a few different options. You can find the print version on Amazon here.

We also have the digital book that has all of the exercises on video and you can find that version by clicking here.

Going To The Provider

Sometimes the injury is more serious than what you can handle at home, you need a second opinion, or your at home therapies haven’t worked and you need to get higher level care.

It’s time to go to the provider. In the Gymnast Care Book on Injuries we discuss who you have on your medical team. Before any injuries occur, you should have good contacts that you can go to in the event of an injury. Here are some of the providers that you should have contacts for:

Here is the Breakdown of the “Provider’s Visit Form”

Below, we describe each section of the form in detail, to make sure you get the provider all of the information that is needed.

Main Complaint

In this section, we want to be as thorough as possible so the doctor knows what the issue is. Here’s an example:

Left heel pain that feels like it is on fire when she punches the floor, vaults or runs.

Be as descriptive as possible to make sure the provider understands the issue.

Parents Observations

This is where you put what you’ve already done and what you see happening at home.

Pain began 3 weeks prior. She has cold water soaked and gently stretched hourly for the past 2 weeks. She has utilized Ibuprofen for the pain. I have massaged her calves every other day. She has used compression at night and when not at practice, and when at practice she has been supporting her arch. After practice she limps around the house and says her heel pain is a 5/10.

Coach’s Observation

Ask your coach to describe what has been done in practice, the coaches observations, and the steps that are being taken to relieve her pain.

She complains of pain when running, punching and vaulting. I have noticed her starting to limp/favor a side when she runs which concerns me. In practice, we stop when she has pain and she cold water soaks for pain relief. She isn’t getting better at this time.

Provider’s Findings & Action Plan

This area is designed for the provider to put their thoughts, or you can write down what the provider talked about during the visit.

Inflammation and pain was noted around the posterior aspect of the calcaneus. Squeeze test was positive. Because she has been attempting conservative treatment without results, an x-ray will be ordered. She will take 2 weeks rest if x-rays are negative to further concentrate on conservative treatment.


This is the condition that the provider has diagnosed your gymnast with. This should be simple, and it is required for insurance billing so they have to have one.

  1. Calcaneal apophysitis/Sever’s disease
  2. Muscle spasm of calf

Gym Restrictions

In our example, the restrictions would be 2 weeks no gym activities. If she hadn’t yet tried conservative therapy at home, the Gym Restrictions would look more like this:

  1. Stop activity if pain is present
  2. No punching board or floor
  3. Keep coach informed of pain

Make sure these are practical and are appropriate for the diagnosis. 30 days no gym is not appropriate unless there is some type of reason why (i.e. back fracture, stress fracture, or other serious issue).

At Home Action Steps

Here is where your provider can put what the plan is for at home care. Here is an example:

  1. Continue with GC heel pain protocol
  2. Take medication as prescribed
  3. Short foot exercises as shown in office
  4. Core control progression

This is where you can start to see the power of the Provider’s Visit Form. The provider felt she needed 2 weeks break, but the provider is using this time to make her a better gymnast. Instead of just sitting at home, now she’s doing the protocol for heel pain, she’s working on foot control, and she progressing with her core control activities.

Expected Return to Full Participation

The Expected Return to Full Participation is important so you and your coaches can know when it is expected to have your gymnast back in the gym. It’s a great communication tool between the provider and your gym.

Expected return to gymnastics activity in 2 weeks. Gymnast will follow up with me in 2 weeks, and if expected reduction in pain is met, she will return to the gym to resume gymnastics. Further update on this after next visit.


For this example, no referrals are needed, however on the ‘Imaging needed‘ line, it will state, “Left foot x-ray at ABC Imaging Center.” The doctor will also submit a digital order to the imaging center, or they will have imaging in the office.

If the doctor were to provide more therapy options, the example would look like this:

Name: Dr. Joshua Eldridge, Gymnast Care

Referral for: Sever’s disease protocol

Signature Box

Many gyms require a provider’s clearance letter and this will give you a chance to submit this to the gym. Again, this is a great communication tool to further build teamwork between parents, coaches, providers, and gymnasts.

Wrap It Up

There it is, and now that you have a plan, it’s not so bad. Go to the provider with confidence, but make sure there is a plan in place. Don’t let the provider not give you a plan, and don’t be timid about making sure each box is accounted for in your Provider’s Visit Form.

If you haven’t yet downloaded your copy, click here to download your Providers Visit Form.

Let us know if you have questions in the comments below.

Dr. Joshua Eldridge

About Dr. Joshua Eldridge

Dr. Joshua Eldridge has specialized in protecting gymnasts from injury. He is the inventor of The X Brace, and has developed a treatment protocol for Sever's disease and heel pain that has helped thousands of gymnasts throughout the world. Dr. Eldridge brings practical, easy injury care and prevention that can be done at home.