School Recommendations Following Concussion

SCHOOL RECOMMENDATIONS FOLLOWING CONCUSSION

Patient Name: ______Date of Birth: ______
Date of Evaluation: ______Referred by: ______
Duration of Recommendations: 1 week2 weeks4 weeksUntil further notice

The patient will be reassessed for revision of these recommendations in ______weeks.

This patient has been diagnosed with a concussion (a brain injury) and is currently under our care. Please excuse the patient from school today due to the medical appointment. Flexibility and additional supports are needed during recovery. The following are suggestions for academic adjustments to be individualized for the student as deemed appropriate in the school setting. Feel free to apply/remove adjustments as needed as the student’s symptoms improve/worsen. ______
AttendanceBreaks

______No school for _____ school day(s)______Allow the student to go to the nurse’s

______Attendance at school _____ days per weekoffice if symptoms increase

______Full school days as tolerated by the student______Allow student to go home if symptoms do

______Partial days as tolerated by the studentnot subside

______Allow other breaks during school day as deemed necessary and appropriate by school personnel

Visual StimulusAudible Stimulus

______Allow student to wear sunglasses/hat in school______Lunch in a quiet place with a friend

______Pre-printed notes for class material or note taker______Avoid music or shop classes

______Limited computer, TV screen, bright screen use______Allow to wear earplugs as needed

______Reduce brightness on monitors/screens______Allow class transitions before bell

______Change classroom seating as necessary
Workload/Multi-TaskingTesting

______Reduce overall amount of make-up work, class______Additional time to complete tests

work and homework______No more than one test a day

______Prorate workload when possible______No standardized testing until ______

______Reduce amount of homework given each night______Allow for scribe, oral response, and oral

delivery of questions, if available

Physical ExertionAdditional Recommendations

______No physical exertion/athletics/gym/recess______
______Walking in gym class only______

______Begin return to play protocol as outlined by______

return to activity form______

Current Symptoms List(the student is noting these today)

______Headache______Visual problems______Sensitivity to noise______Memory issues

______Nausea ______Balance problems______Feeling foggy______Fatigue

______Dizziness______Sensitivity to light______Difficulty concentrating______Irritability
Student is reporting most difficulty with/in
______All subjects______Reading/Language arts______Foreign Language______Math

______Science______Music______History______Using Computers

______Focusing______ListeningOther: ______

______
XXXXXXXXXXXX, MD
XXXXXXXXXXXXXXXXXXXX
Office (XXX)XXX-XXXX Fax (XXX)XXX-XXXX / I, ______, give permission for Dr. XXXXXXXXX to share the following information with my child’s school and for communication to occur between the school and Dr. XXXXXXX for changes to this plan
______
Parent Signature Date

This form may be duplicated or changed to suit your needs and your patients’ needs.