Get Concussion Evaluation

This guide provides clear and supportive instructions on how to complete the Concussion Evaluation online. By carefully following these steps, you will ensure that all necessary information is accurately captured for effective evaluation.

Follow the steps to fill out the form accurately and completely.

1. Press the 'Get Form' button to obtain the Concussion Evaluation form and open it in your preferred editor.
2. Begin by entering the athlete's name, sport level, and date and time of the evaluation at the top of the form.
3. In the 'Evaluator' section, provide the name of the person conducting the evaluation.
4. Under 'Injury Characteristics', indicate whether there is evidence of a forcible blow to the head by selecting 'Yes', 'No', or 'Unknown'. Describe the nature of the injury in the designated space.
5. Provide specific details about the location of the impact by circling the relevant areas (e.g., frontal, temporal, parietal).
6. Rate each symptom listed in the Post Concussion Symptom Scale according to the severity experienced by the user (0 for none, 1-2 for mild, 3-4 for moderate, and 5-6 for severe).
7. Complete the Balance Error Scoring System section by recording any errors made during the balance tests.
8. Answer the orientation questions (month, date, day of the week, year, and time) with best effort, marking as pass or fail.
9. Perform the memory test, recalling as many words as possible from the list after reading. Mark pass or fail for this trial.
10. For concentration, respond to the digits backwards exercise, marking pass or fail as needed.
11. After all tests, assess exertion conditions if symptoms are not currently displayed. Mark physical and cognitive activities as applicable.
12. Document the neurological screening results, including loss of consciousness, tinnitus, and other neurological signs.
13. Record the diagnosis and any prior concussions in the designated section.
14. Outline the action plan, including the person or entity to whom the athlete is being released and any follow-up advice.
15. Once all fields are completed, save your changes. You may also choose to download, print, or share the form as needed.

Start filling out your Concussion Evaluation online today for comprehensive assessment!