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Head Injury Diagnosis and Management Form
Name: ______DOB:______
Date of injury: ______
Diagnosis:  Concussion  Head injury (no concussion)  Other: ______
Recomendations:
 No restrictions; no follow-up necessary unless develops further symptoms.
 Athletes who suffer concussion should follow a six-step, symptom-limited, return to play process as follows:
Step 1: No activity - Complete physical and cognitive rest (includes no homework, text messaging or video games).
Step 2: Light aerobic exercise - Walking or stationary bicycle.
Step 3: Sport-specific exercise - Skating drills in ice hockey, running drills in soccer. No head impact activities.
Step 4: Non-contact training drills - Progression to more complex training drills, e.g. passing drills in football and ice hockey.
Step 5: Full contact practice - Following medical clearance, participate in normal training activities.
Step 6: Return to full activities.
Each step should take a minimum of 24 hours and the athlete has to be able to perform that step symptom free. If symptoms develop, the individual should return to the previous step and proceed as above. Most individuals who suffer from concussion can complete this process in 7-10 days, but some may require more time.
The above steps should be monitored by the coach or trainer. After completing step 4 the coach or trainer should sign below, the athlete should then be reexamined by a medical provider prior to initiating step 5.
Initial Recommendation: / Date:
Physician/Nurse Practitioner*
Has completed steps 1-4: / Date:
Coach/Trainer
Cleared to return to contact practice, then to play after completes step 5: / Date:
Physician/Nurse Practitioner*

·  I attest that I have received clinical training in post-traumatic head injury assessment and management approved by the Massachusetts Department of Public Health.

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