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Office use only: Date: Exam Room: Moderator: Alt. ID# Baseline Worksheet I. General Information Demographic and Background Information Name DOB Height Weight School/ Organization Handedness: R or
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How to fill out the UPMC Concussion Program:

01
Visit the official website of UPMC Concussion Program.
02
Click on the "Forms" or "Fill out the Program" section.
03
Read the instructions carefully before starting the program.
04
Provide your personal information such as name, date of birth, and contact details.
05
Answer the questionnaire regarding your concussion history, symptoms, and any previous treatment received.
06
If applicable, provide details about the healthcare professional who diagnosed your concussion.
07
Fill out any additional sections or forms required by the program, such as consent forms or medical release forms.
08
Review and double-check all the information provided for accuracy.
09
Submit the completed forms electronically or print them out and mail them to the designated address.
10
After submitting the forms, wait for further instructions and follow any additional steps provided by the UPMC Concussion Program.
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UPMC Concussion Program is a comprehensive program that provides evaluation, treatment, and management for individuals who have suffered a concussion.
Anyone who has suffered a concussion and is seeking evaluation or treatment from UPMC Concussion Program is required to file a concussion program.
To fill out UPMC Concussion Program, individuals need to schedule an appointment for evaluation and treatment with the program's healthcare providers.
The purpose of UPMC Concussion Program is to provide specialized care for individuals who have experienced a concussion, helping them recover and manage their symptoms.
Information such as medical history, symptoms, previous concussions, and current symptoms must be reported on UPMC Concussion Program.
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