Get the free 2011-12 Physician Concussion Form 2011 - schalick pittsgrove

PHYSICIAN CONCUSSION EVALUATION FORM A.P. CHALICE HIGH SCHOOL 718 Center ton Road Pitts grove, NJ 08318 Mrs. Joann Klaus, Nurse (856) 358-2054 Fax: (856) 358-7512 Ms. Lottie Lower, Athletic Trainer

How to fill out 2011-12 physician concussion form

1. The 2011-12 physician concussion form is typically required for individuals who have suffered a head injury or concussion and are seeking medical evaluation or treatment. This form helps healthcare professionals gather important information about the individual's symptoms, medical history, and the circumstances surrounding the injury.
2. Start by carefully reviewing the instructions on the form. It is crucial to understand what information is being asked for and how it should be provided. Familiarize yourself with the different sections and the purpose of each.
3. In the "Patient Information" section, provide your personal details such as name, date of birth, address, and contact information. This information will help healthcare providers identify you and maintain accurate records.
4. The "Description of Injury" section requires you to provide a detailed account of how the head injury or concussion occurred. Include the date, time, and location of the incident, as well as any specific events that led to the injury. This information is important for evaluating the severity and potential causes of the injury.
5. In the "Symptoms" section, list all the symptoms you have been experiencing since the injury. Common symptoms may include headaches, dizziness, memory problems, difficulty concentrating, and sensitivity to light or noise. Be as specific as possible to help healthcare providers assess your condition accurately.
6. You may be asked to provide a brief medical history in the "Medical Background" section. Include any prior head injuries, concussions, or relevant medical conditions. This information will assist healthcare providers in understanding your overall health and potential risk factors.
7. The form may also include a section for healthcare providers to document their examination findings and recommended treatments. If you are filling out this form on behalf of someone else, leave this section blank and let the healthcare professional fill it out.
8. Finally, review the completed form to ensure all information is accurate and complete. Make sure you have signed and dated it as required.
9. Keep a copy of the filled-out form for your records and submit the original to the designated healthcare provider or institution requesting it.

In summary, anyone who has suffered a head injury or concussion and requires medical evaluation or treatment may need to fill out the 2011-12 physician concussion form. It helps healthcare professionals gather necessary information about the individual's injury, symptoms, medical history, and recommended treatments.

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What is 12 physician concussion form?

The 12 physician concussion form is a document used to report cases of concussions diagnosed by healthcare professionals.

Who is required to file 12 physician concussion form?

Schools, sports organizations, and healthcare providers are required to file the 12 physician concussion form.

How to fill out 12 physician concussion form?

To fill out the 12 physician concussion form, one must provide information about the individual with the concussion, the healthcare provider diagnosing the concussion, and details about the incident.

What is the purpose of 12 physician concussion form?

The purpose of the 12 physician concussion form is to track and report cases of concussions for research and safety reasons.

What information must be reported on 12 physician concussion form?

The 12 physician concussion form must include information about the individual with the concussion, the healthcare provider diagnosing the concussion, and details about the incident.