Community Volleyball Player
Concussion Screening Template

Player Information

Player Name Date Team Age

Incident Details

Incident Date/Time Brief Description of Incident Was loss of consciousness observed? Yes No Additional Details

Symptoms Checklist

Headache Dizziness Nausea Confusion Memory loss Blurry vision Other Other Symptoms (specify)

Physical Assessment

Balance/gait assessment findings Coordination test findings Cognitive assessment findings

Recommendations

Recommendations/Follow-up Actions