Concussion Evaluation and Treatment
Concussion Initial Evaluation Date: Patient Name: Date of Birth: DOI: Presence of Red Flags (Y/N): MOI: Imaging: Medications: History: (Y/N) Description Previous concussions Total Number: Dates: History of Migraines (Y/N): Aura: Triggers: Allergies Medications Neurocognitive Baseline Hx Completed (Y/N) Date Completed Location completed Pass / Fail Baseline Neurocognitive Testing Completed (ImPACT) Neurocognitive Testing Completed Post-Injury Subjective: Concussion Symptom Checklist Please report your symptoms on the following scale: 0 = no symptoms; 6 = severe symptoms. If you are being seen post-injury please fill out based on how you feel at this moment in time. If you are being seen for baseline screening, please fill out based on how you typically feel. Baseline or Post injury: None Mild Moderate Severe Headache 0 1 2 3 4 5 6 “Pr...