Sports Medicine Concussion Evaluation

Sports Medicine Concussion Evaluation — Form Fields

This healthcare template includes 14 fields. Standardized concussion evaluation form for athletes following head injury. Free to customize and use on ZenBuild.

• Athlete Name (text, required)
• Date of Birth (text, required)
• Sport (text, required)
• Date and Time of Injury (text, required)
• Evaluator Name (text, required)
• Mechanism of Injury (dropdown selection, required) — options: Direct Head Contact, Whiplash/Indirect, Fall, Collision with Player, Hit by Object, Unknown
• Loss of Consciousness (multiple choice, required) — options: Yes, No, Uncertain
• Duration of LOC (if applicable) (dropdown selection, optional) — options: Seconds, Under 1 Minute, 1-5 Minutes, Over 5 Minutes
• Symptoms Present (checkboxes, required) — options: Headache, Dizziness, Nausea, Blurred Vision, Sensitivity to Light, Sensitivity to Noise, Feeling Foggy, Memory Problems, Confusion, Balance Problems, Drowsiness
• Symptom Severity (overall) (dropdown selection, required) — options: Mild, Moderate, Severe
• Oriented to Person Place Time (multiple choice, required) — options: Yes - All Three, Partially, No
• Ambulance Called (multiple choice, required) — options: Yes, No
• Description of Incident (long text, required)
• Immediate Management and Recommendations (long text, required)