Concussion History Disclosure Form for Athletes

Athlete Information

Full Name Date of Birth Sport Team/Organization

Concussion History

How many diagnosed concussions have you had? Date of most recent concussion Have you ever experienced symptoms of concussion but did not report them? Yes No

Details of Past Concussions

#	Date	Cause (e.g., sport, fall)	Symptoms	Time to Recovery (days)
1
2
3

Additional Relevant Medical History or Comments

Athlete Signature Date