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CONCUSSION INTAKE FORM Background Name: Date: INJURY INFORMATION Date of injury: Time of day: ED Referral: Yes No Describe injury: Cause of injury: MVA Fall Assault Sport (If yes, which sport?) Other:

How to fill out concussion intake form

How to fill out a concussion intake form:

1. Start by carefully reading the instructions provided with the form. This will ensure that you understand the purpose of the form and what information you need to provide.
2. Begin by filling out your personal information, such as your name, date of birth, and contact details. Make sure to write legibly and provide accurate information.
3. Next, you may be asked to provide details about your medical history. This can include previous concussions, any related symptoms you've experienced, and any previous treatment or medical interventions you've received.
4. The form may also ask about your current symptoms, if any, and how they have been affecting your daily life. Be thorough and honest while describing your symptoms.
5. If applicable, you may need to provide information about any medications you are currently taking or have taken in the past.
6. Take your time to read and understand any additional questions or sections of the form. Some forms may ask about your current activities, job, or sports participation.
7. Finally, review your answers to ensure accuracy and completeness. If you have any questions or concerns about the form, do not hesitate to seek clarification from a healthcare provider or the person administering the form.

Who needs a concussion intake form?

1. Athletes: Individuals participating in contact sports or activities with a risk of head injury may be required to complete a concussion intake form. This helps evaluate their risk factors and monitor their health in relation to any potential concussions.
2. Military personnel: As head injuries are common in military environments, especially during training or combat, concussion intake forms may be required to assess and track the health of soldiers.
3. Students: Some schools and educational institutions may require concussion intake forms from students participating in sports or physical activities, as a precautionary measure to ensure their safety and provide appropriate care if a head injury occurs.
4. Workplace employees: Certain industries, such as construction or manufacturing, may implement concussion intake forms to identify potential workplace hazards or incidents and ensure prompt medical attention for employees who have suffered a head injury.
5. Medical facilities: Hospitals and clinics may use concussion intake forms to gather comprehensive information about patients who have experienced head injuries. This data assists healthcare professionals in diagnosing and treating concussions effectively.

For pdfFiller’s FAQs

What is concussion intake form?

The concussion intake form is a document used to gather information about a person who has experienced a concussion.

Who is required to file concussion intake form?

Athletes, coaches, and parents are typically required to file the concussion intake form.

How to fill out concussion intake form?

The concussion intake form can be filled out by providing personal information, details of the concussion, and any related symptoms.

What is the purpose of concussion intake form?

The purpose of the concussion intake form is to ensure that proper care and monitoring are provided to individuals who have experienced a concussion.

What information must be reported on concussion intake form?

Information such as the date of the concussion, symptoms experienced, and any previous history of concussions must be reported on the concussion intake form.

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