Get the free Concussion Referral Form - SUNY Upstate Medical University - upstate

*DT82635* Concussion Management Program Sports Concussion Program 750 East Adams Street Patient Name: Account #: MR#: Syracuse, NY 13202 Tel 315.464.8986 DOB: Fax 315.464.2329 Date: www.upstate.edu/concussion

How to fill out concussion referral form

How to fill out a concussion referral form:

1. Start by accessing the concussion referral form, which can typically be obtained from a healthcare provider, school, or sports organization.
2. Clearly write your personal information, including your full name, date of birth, address, and contact information.
3. Provide details about the incident that led to the possibility of a concussion, such as the date and time it occurred, the location, and a brief description of the event.
4. Indicate any symptoms or signs of a concussion that you have experienced since the incident, such as headache, dizziness, memory problems, or sensitivity to light or noise.
5. If you have sought medical attention or received any initial treatment for the concussion, specify the healthcare provider's name, contact information, and any medications or recommendations provided.
6. Sign and date the form to confirm the accuracy of the information provided.
7. Submit the completed concussion referral form to the appropriate recipient, whether it is a healthcare provider, school nurse, or sports organization.

Who needs a concussion referral form:

1. Athletes: Concussion referral forms are often required for athletes participating in sports that carry a risk of head injuries, such as football, soccer, hockey, and basketball. These forms help ensure that any potential concussions are properly evaluated and treated to protect the athlete's well-being.
2. Students: Schools may require students to complete a concussion referral form if they are involved in activities or physical education classes that could lead to head injuries. This helps schools track and respond to potential concussions to ensure the student's safety.
3. Healthcare providers: If a healthcare provider suspects that a patient may have suffered a concussion, they may request the patient or their guardian to complete a concussion referral form. This allows for a comprehensive understanding of the incident and the patient's symptoms, aiding in accurate diagnosis and appropriate treatment.

For pdfFiller’s FAQs

What is concussion referral form?

The concussion referral form is a document used to report and document instances of concussion in individuals.

Who is required to file concussion referral form?

Healthcare professionals or coaches who suspect an individual has suffered a concussion are required to file the concussion referral form.

How to fill out concussion referral form?

The concussion referral form must be filled out with the individual's personal information, details of the suspected concussion, and any relevant medical history.

What is the purpose of concussion referral form?

The purpose of the concussion referral form is to ensure that individuals who have suffered a concussion receive the appropriate medical attention and care.

What information must be reported on concussion referral form?

Information such as the individual's name, age, symptoms of concussion, suspected cause of injury, and any previous head injuries must be reported on the concussion referral form.

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