Head Injury Evaluation Record

Global Concepts Charter School

Athlete Name ______

Head Injury Evaluation Record

Global Concepts Charter School uses the following guidelinesand ImPACT testingin determining if and when an athlete may return to play following a concussion. These guidelines are based on the awareness of the increased vulnerability of the brain to concussions occurring close together and the cumulative effects of multiple concussions on long-term cognitive function. The student must be evaluated and have documentation of protocol reviewed by a School or Private physician.

ImPACT stands for Immediate Post Concussion Assessment and Cognitive Testing. The program is used by a majority of professional and collegiate teams and is now being utilized by Global Concepts Charter School. ImPACT is a computer-based test that measures an athlete’s memory, reaction time and concentration. A baseline test is taken prior to the start of the athlete’s season. If the athlete suffers a concussion, they are re-tested on ImPACT prior to their full return to play to reassess their level of cognitive function. An athlete who suffers a concussion is to rest both physically and mentally until symptom free. The return to play protocol allows for a gradual reintroduction to activity. The progression is from low impact exercise (walking, stationary bike) to light aerobic exercise / sport specific exercises (running, skating) then advancement to non-contact training/drills. If the athlete remains symptom free, progression is to full contact practice, then full participation.

DATE OF INJURY ______ Post Concussion Symptoms

Date / Symptoms / Init.
+

+If symptoms remain after 7 days - Refer to specialist or concussion clinic

Initial/signature ______

ImPACT retest date(s) ______

Return to Play Guidelines

Step / Activity / Plan / date / Notes/init.
1. No Activity / Complete physical & cognitive rest / Will advance to step 2 when asymptomatic for 48 hrs after concussion
2. Light aerobic activity / Stationary bike, walking / Proceed to the next step on the following day if remains asymptomatic
3. Sport Specific exercise / Skating drill, running drills – no head impact activity / Same as above
4. Non-Contact training drills / Progress to more complex training drills. May begin resistive training. / Same as above
5. Full contact practice / Participate in normal training/practice activities / Same as above / ImPACT retest date(s) ______
6. Return to play / Normal game play / ----

Physician Release:

“ I have reviewed the above 2009 ZurichRecommended Return to Play Guidelines and the athletic trainers injury report (reverse side of this form)and it is my medical opinion that ______

Name of Athlete

is cleared to participate in Physical Education class and sports as per the above Return to Play guidelines ”

Date______Health Care Provider Signature______

Health Care Provider printed name______

Global Concepts Charter Athlete Name ______

Head Injury Report

DOB ______

ASSESSMENT TO BE COMPLETED BY ATC AT SIDELINE

Sport ______Location______

Date ______Time ______Equipment worn______

Point of impact ______

History______

Previous Concussion(s) N Y approx date(s) ______(Not Assessed at sideline ___)

Above data completed by school nurse only if athlete was not assessed at sideline, RN sign.______

OBSERVATIONS by STAFF
LOC
Length of time ______/ N Y
Retrograde Amnesia / N Y
Post traumatic amnesia / N Y
Confusion/Disorientation / N Y
Balance or Gait issues / N Y
Abnormal Visual Process / N Y
Abnormal appearance or behavior / N Y
Seizure or posturing / N Y
Vomiting / N Y
COGNITIVE EXAM
Oriented to place / N Y
Oriented to day of week / N Y
Oriented to current time / N Y
# of numbers repeated correctly
# of words repeated correctly
# words repeated correctly ( delayed)
BALANCE/ EYE EXAM
Standing, feet together / Fail Pass
Standing , one leg / Fail Pass
Tandem Gait / Fail Pass
Visual Tracking / Fail Pass
PERRLA / Fail Pass
SYMPTOMS REPORTED BY ATHLETE
Headache / N Y
Dizziness / N Y
Balance problems / N Y
Blurred vision / N Y
Double vision / N Y
Problems focusing ( visually) / N Y
Problems tracking ( visually) / N Y
Sensitivity to light / N Y
Sensitivity to noise / N Y
Tingling/loss of movement / N Y
Pain in neck / N Y
‘Foggy’, ‘Cloudy’, ‘Spaced out’ / N Y
Problems focusing ( mentally) / N Y
Problems remembering / N Y
Abnormally tired / N Y
Upset. Emotional / N Y
TOTAL
Parent notified / N Y
Instructions given to
Parent student (parent unavailable)
Signature of examiner
COMMENTS