Get Duke Sports Medicine Concussion Evaluation Patient Name: Duke Mr# Dob: Age: Date: School: Injury

Filling out the Duke Sports Medicine concussion evaluation form is essential for assessing a person's health after a potential head injury. This guide provides clear instructions to help you complete the form accurately and effectively.

Follow the steps to successfully complete the concussion evaluation form.

1. Click the ‘Get Form’ button to access the evaluation form online.
2. Begin by entering the patient's information in the designated fields. Fill in the patient's name, medical record number (MR#), date of birth (DOB), age, date of evaluation, and school.
3. In the injury characteristics section, record the date and time of the injury. Designate who is reporting the injury, selecting from options such as patient, parent, spouse, or other.
4. Provide a detailed injury description that captures all relevant details about the incident.
5. Answer the yes/no questions regarding evidence of a forcible blow to the head, intracranial injury, and location of impact. Make sure to check all applicable boxes.
6. Indicate the cause of the injury by selecting from options like motor vehicle collision (MVC), pedestrian/MVC, fall, assault, or sports, and specify if necessary.
7. Record answers to amnesia questions, noting any loss of memory before or after the injury and their durations.
8. Indicate if there was a loss of consciousness and specify the duration.
9. Check any early signs observed after the injury, such as confusion or memory issues.
10. If seizures were observed, acknowledge that in the relevant section with additional details.
11. Complete the risk factors for protracted recovery section, checking any applicable history of concussions, headaches, or developmental and psychiatric history.
12. Assess symptoms in the symptom evaluation section, scoring each symptom based on severity, both currently and at the time of the injury.
13. Answer the questions regarding symptom exacerbation with physical and mental activity.
14. Give an overall rating of how different the athlete appears compared to their usual self.
15. Once all sections are filled out, review the information for accuracy and completeness. Save your changes, and you can choose to download, print, or share the completed form.

Complete the Duke Sports Medicine concussion evaluation form online today for accurate assessment and care.