Toronto Ultimate Club Suspected Concussion Report Form

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Email *

1. Participant Name *

2. Participant Date of Birth *

YYYY

3. Date of Injury *

YYYY

4. Time of Injury *

Time

5. Name of Program/League/Event where the Injury occurred at *

6. Location *

7. Injury Description *

8. Reported Symptoms (Check all that apply) *

Heahache

Nausea

Dizziness

Vomiting

Visual Problems

Balance Problems

Numbness/tingling

Feeling mentally foggy

Feeling slowed down

Difficult concentrating

Drowsiness

Sleeping more/less than usual

Trouble falling asleep

Sensitive to light

Sensitive to noise

Irritability

Sadness

Nervous/anxious

More emotional

Fatigued

None

Other:

Required

9. Red Flag Symptoms (Check all that apply): Call 911 Immediately with a sudden onset of any of these symptoms *

Headache that worsen

Seizures or convulsions

Repeated vomiting

Loss of consciousness

Looks very drowsy/can't be awakened

Slurred speech

Can't recognize people or places

Increasing confusion or irritability

Weakness or numbness in arms/legs

Persistent or increasing neck pain

Unusual behavioural change

Focal neurologic signs (e.g. paralysis, weakness, etc.)

Was 911 Called: Yes

Was 911 Called: No

Required

10. Are there any OTHER observable/reported symptoms *

Yes

11. If you responded "yes" to Question 10, what were the other observable/reported symptoms?

12. Is there evidence of injury to anywhere else on body besides head? *

Yes

13. If you responded "yes" to Question 12, where?

14. Has this player had a concussion before? *

Yes

Prefer not to answer

15. If you responded "yes" to Question 14, how many?

16. Does this player have any pre-existing medical conditions? *

Yes

Prefer not to answer

17. If you responded "yes" to Question 16, please list:

18. Does this player take any medication? *

Yes

Prefer not to answer

19. If you responded "yes" to Question 18, please list:

20. Name of Person completing this form *

Name of the person who has suspected a concussion, and has recommended to the player's parent/guardian that the player sees a medical professional immediately. A medical professional includes a medical doctor, family doctor, pediatrician, emergency room doctor, sports-medicine physician, neurologist or nurse practitioner.

21. Role of the person completing this form *

Role of the person completing this form: Coach, Responsible Adult, Most Caring Individual, TUC Staff Member, etc.

22. Date the Report was submitted *

YYYY

Send me a copy of my responses.

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