Player Concussion Assessment Report
Player Name
Date of Assessment
Team
Assessed By
Time of Injury
Location of Injury
Mechanism of Injury
Symptoms Observed
Observable Signs (tick or note below)
Sign
Present
Loss of consciousness
Disorientation/confusion
Balance difficulties
Seizure/convulsion
Vomiting
Other
Initial First Aid/Action Taken
Cognitive Assessment
Memory Assessment
Physical Assessment
Recommendations / Follow-up