Age (number only):
Sex: Gender: Male Female
School:
Sport of participation:
Number of concussions in lifetime:
Number of concussions in last 12 months:
Number of concussions in last 6 months:
Date and time of current concussion: Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , Year 2010 2011 2012 2013 2014 2015 , Hour 01 02 03 04 05 06 07 08 09 10 11 12 , Minute 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 , AM/PM: AM PM
Was there loss of consciousness?: Loss Consciousness(Y/N): Yes No , If yes, how long:
Was there amnesia?: Amnesia(Y/N): Yes No , If yes, how long: If yes, what type: Type of Amnesia: Retrograde Antigrade
Were there other unique circumstances:
Date and time noted to be symptom free for 12 hours: Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , Year 2010 2011 2012 2013 2014 2015 , Hour 01 02 03 04 05 06 07 08 09 10 11 12 , Minute 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 , AM/PM: AM PM
SCAT performance at asymptomatic evaluation: 5 immediate recall 0/5 1/5 2/5 3/5 4/5 5/5 , Reversed numbers:(number only):, Delayed recall items: 0/5 1/5 2/5 3/5 4/5 5/5
Baseline SCAT performance if needed: 5 immediate recall 0/5 1/5 2/5 3/5 4/5 5/5 , Baseline SCAT Reversed numbers:(number only):, Delayed recall items: 0/5 1/5 2/5 3/5 4/5 5/5
Date and time clearance given to start progression back to participation: Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , Year 2010 2011 2012 2013 2014 2015 , Hour 01 02 03 04 05 06 07 08 09 10 11 12 , Minute 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 , AM/PM: AM PM
Date and time given follow up neuropsychological testing: Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , Year 2010 2011 2012 2013 2014 2015 , Hour 01 02 03 04 05 06 07 08 09 10 11 12 , Minute 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 , AM/PM: AM PM
Did follow up neuropsychological test cause any symptom recurrence? Symptom recurrence?(Y/N): Yes No
Has this patient ever been diagnosed with ADD or ADHD? ADD or ADHD?(Y/N): Yes No
Has this patient been diagnosed with a learning disability? Learning disability?(Y/N): Yes No ,If yes,explain:
Was the patient able to complete return to play progression without setback? Complete return to play?(Y/N): Yes No ,If not,explain:
Were there other complications?(Including after complete return to play