Get the free Concussion Referral Form

This form is used for referring student-athletes for concussion evaluation and management, ensuring they meet the criteria to safely return to play after a suspected concussion.

How to fill out concussion referral form

How to fill out concussion referral form

1. Start by gathering the required patient information, including their name, age, and contact details.
2. Provide details about the incident that caused the concussion, including date, time, and location.
3. Fill in the patient’s medical history relevant to head injuries or concussions.
4. Complete the symptoms section by checking all applicable symptoms experienced by the patient.
5. Include information about any prior concussions or neurological evaluations the patient has undergone.
6. Sign and date the form, and ensure that all necessary fields are filled out accurately.
7. Submit the completed form to the designated healthcare professional or facility for review.

Who needs concussion referral form?

1. Individuals who have sustained a head injury and exhibit signs or symptoms of a concussion.
2. Athletes who experience head impacts during sports activities.
3. Children and teenagers who require evaluation for potential concussions.
4. Anyone involved in activities that pose a risk of head injury, such as contact sports or high-impact activities.

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What is concussion referral form?

A concussion referral form is a document used to report and assess an individual's injury, specifically for concussions. It is typically required when an athlete or individual experiences symptoms of a concussion and seeks further evaluation by healthcare professionals.

Who is required to file concussion referral form?

The concussion referral form is typically filed by coaches, athletic trainers, or healthcare providers responsible for the care of athletes, especially in sports settings. It may also be filled out by parents or guardians when a concussion is suspected.

How to fill out concussion referral form?

To fill out a concussion referral form, one should provide relevant information including the individual's personal details, the circumstances of the injury, symptoms observed, medical history, and any previous concussions. It's important to ensure that all sections of the form are completed accurately.

What is the purpose of concussion referral form?

The purpose of the concussion referral form is to facilitate communication between parties about an individual's concussion status, ensure a proper assessment is conducted, and document the injury for future reference and care.

What information must be reported on concussion referral form?

The information that must be reported on a concussion referral form typically includes the patient's name, date of birth, date of the incident, description of how the injury occurred, symptoms noted, any prior concussion history, and signatures of the person completing the form.