Concussion Incident and Management Report

Patient Information

Age (number only):



Sport of participation:

Number of concussions in lifetime:

Number of concussions in last 12 months:

Number of concussions in last 6 months:

Date and time of current concussion:
, , , ,

Was there loss of consciousness?:
, If yes, how long:

Was there amnesia?:
, If yes, how long: If yes, what type:

Were there other unique circumstances:

Date and time noted to be symptom free for 12 hours:
, , , ,

SCAT performance at asymptomatic evaluation:
, Reversed numbers:(number only):,

Baseline SCAT performance if needed:
, Baseline SCAT Reversed numbers:(number only):,

Date and time clearance given to start progression back to participation:
, , , ,

Date and time given follow up neuropsychological testing:
, , , ,

Did follow up neuropsychological test cause any symptom recurrence?

Has this patient ever been diagnosed with ADD or ADHD?

Has this patient been diagnosed with a learning disability?
,If yes,explain:

Was the patient able to complete return to play progression without setback?
,If not,explain:

Were there other complications?(Including after complete return to play