Get Ace Concussion Evaluation Form

Filling out the Ace Concussion Evaluation Form online is a crucial step in assessing and managing concussions effectively. This guide provides you with a step-by-step approach to ensure that the form is completed thoroughly and accurately.

Follow the steps to complete the Ace Concussion Evaluation Form online.

1. Click ‘Get Form’ button to obtain the Ace Concussion Evaluation Form and open it in the editor.
2. Enter the patient’s name, date of birth, and the date of the evaluation at the top of the form.
3. For section A (Injury Characteristics), fill in the date and time of the injury, patient's age, and ID/MR# as applicable.
4. For the reporter field, indicate whether the reporter is the patient, parent, spouse, or other.
5. Injury description: Answer questions 1a to 1c regarding evidence of a forcible blow, intracranial injury, and location of impact.
6. For question 2, specify the cause of the injury from the provided options.
7. Answer questions regarding amnesia before (question 3) and after (question 4) the injury, indicating duration if applicable.
8. Indicate whether there was a loss of consciousness in question 5 and describe its duration.
9. For early signs of concussion (question 6), select all observed symptoms from the list.
10. Question 7 inquires about seizures observed; please provide details if applicable.
11. Section B (Symptom Checklist): Indicate the presence of each symptom (physical, cognitive, sleep) within the last day using the scoring system.
12. Calculate totals for physical, cognitive, emotional, and sleep symptoms as per the instructions.
13. Inquire and document if symptoms worsen with physical or cognitive exertion as stated in the exertion section.
14. Assess the individual’s overall rating based on how different they are from their usual self.
15. For section C (Risk Factors for Protracted Recovery), check all applicable risk factors and provide additional history as required.
16. In section D, be alert for red flags that may indicate the need for emergency evaluation.
17. Fill out section E (Diagnosis) by selecting the appropriate ICD code based on the assessment.
18. Complete section F (Follow-Up Action Plan) by outlining the next steps for monitoring or referrals as necessary.
19. Finally, ensure the form is completed with the evaluator's name and any necessary signatures.
20. Once all the information is filled out, save changes, and choose to download, print, or share the form as needed.

Complete the Ace Concussion Evaluation Form online today for swift and accurate assessment.