Gymnastics Concussion Baseline Information Sheet

Athlete Information

Full Name Date of Birth Age Gymnastics Club Coach Name Competitive Level

Emergency Contacts

Parent/Guardian Name Phone Number

Medical History

Previous Concussion(s)? Yes No If yes, how many? Other relevant medical conditions (e.g. migraines, ADHD, learning disability, etc.) Current Medications

Baseline Symptom Checklist

Symptom	None	Mild	Moderate	Severe
Headache
Dizziness
Nausea/Vomiting
Fatigue
Difficulty Concentrating
Memory Problems
Trouble Sleeping
Emotional Changes

Notes