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PHYSICIAN CONCUSSION EVALUATION FORM Pascal Valley High School Athletic Training and Sports Medicine Bill Refer, MA, ATC Phone: (201) 358-7060 x4036 Fax: (201) 358-7102 Dear Physician: Date: has/may

How to fill out physician concussion evaluation form

How to fill out a physician concussion evaluation form:

1. Begin by providing personal information: Fill in your name, date of birth, and contact information. This information is essential for identification purposes and follow-up communication.
2. Medical history: Carefully review the form and answer questions about any previous concussions or head injuries you may have had. Include details such as the date, symptoms experienced, and any previous treatments undertaken.
3. Present symptoms: Describe the current symptoms you are experiencing. These may include headaches, dizziness, memory problems, sensitivity to light or noise, or any other signs of a possible concussion. Be as specific as possible and provide accurate information.
4. Circumstances of injury: Note down the details of the incident that led to the potential concussion. Describe the event, the force of impact, and any associated factors, such as whether protective equipment was worn or if there was any loss of consciousness.
5. Physical examination: If a healthcare professional is conducting the evaluation, they may perform certain physical tests to assess cognitive function, coordination, balance, and reflexes. These will help determine the severity of the concussion and guide treatment.
6. Additional tests: In some cases, additional tests may be necessary to further evaluate the extent of the head injury. These tests may include imaging studies like a CT scan or MRI, as well as cognitive assessments or neurocognitive testing.
7. Follow-up plan: Based on the evaluation, the healthcare provider will recommend an appropriate course of action. This may involve rest, medication, physical therapy, referral to a specialist, or any other needed treatment.

Who needs a physician concussion evaluation form?

1. Athletes: People involved in sports, especially contact sports like football, hockey, or soccer, are at a higher risk of sustaining concussions. It is important for athletes to undergo an evaluation to ensure they receive appropriate care and can safely return to play.
2. Accident victims: Individuals who have been involved in accidents, such as car crashes or falls, may experience head injuries that require evaluation for potential concussions. Prompt medical attention is crucial to assess and treat these injuries effectively.
3. Military personnel: Military personnel, particularly those deployed in combat zones, are at a higher risk of concussions due to explosive blasts or other combat-related incidents. Regular evaluations help identify and manage these injuries among service members.
4. Anyone with head trauma: Concussions can occur in various situations, including workplace accidents, recreational activities, and everyday accidents at home. If you experience head trauma and exhibit symptoms of a concussion, it is important to seek medical evaluation.

Remember, seeking medical attention and following proper evaluation procedures is crucial in identifying and treating concussions appropriately. Always consult a healthcare professional for a comprehensive assessment tailored to your specific situation.

For pdfFiller’s FAQs

What is physician concussion evaluation form?

The physician concussion evaluation form is a document used to assess and diagnose concussions in athletes.

Who is required to file physician concussion evaluation form?

Coaches, parents, or other certified medical personnel are required to file the physician concussion evaluation form for athletes who have potentially sustained a concussion.

How to fill out physician concussion evaluation form?

The physician concussion evaluation form must be filled out by a licensed medical professional, providing detailed information about the athlete's symptoms, history, and physical examination findings.

What is the purpose of physician concussion evaluation form?

The purpose of the physician concussion evaluation form is to ensure that athletes who have sustained a concussion receive proper medical evaluation and treatment.

What information must be reported on physician concussion evaluation form?

The physician concussion evaluation form typically includes information about the athlete's symptoms, history of injury, physical examination findings, and recommendations for further care.

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