Concussion Check List

Here is a concussion checklist that is also approved and endorsed by the New York State Public High School Athletic Association. This checklist is quite comprehensive and can be used at any time it is suspected that a person has suffered from a concussion.

Concussion Check List:

Name:
Age:
Date of injury:
Time of injury:
Description of injury:

Was there a loss of consciousness?                Yes      No       Unclear
Does he/she remember the injury?                     Yes    No       Unclear
Does he/she have confusion after the injury?      Yes      No       Unclear

Symptoms observed at the time of injury:

Vertigo                                    Yes                  No
Headache                               Yes              No
Tinnitus                                    Yes                  No
Nausea/vomiting                    Yes                  No
Drowsy/sleepy                        Yes                  No
Fatigue/low energy                 Yes                 No
Do not feel right                       Yes                 No
Feeling dazed                          Yes                 No
Seizure                                     Yes                  No
Poor balance/coordination     Yes                No
Memory problems                    Yes                  No
Loss of orientation                 Yes                No
Blurred vision                           Yes                  No
Sensitivity of light                      Yes                  No
Vacant stare/                            Yes                  No
Sensitivity to noise                    Yes                  No
Glassy Eyed                               Yes                  No
Fatigue or low                            Yes              No
Sleeping more than usual         Yes                  No
Energy                                         Yes              No
Slurred speech                          Yes                  No
Sadness                                     Yes              No
Numbness/Tingling                   Yes                  No
Personality changes                 Yes              No

Other findings/comment:

Physical Evaluation:

Date of evaluation: ___________________ Time of evaluation_______________

Symptoms observed:                     Initial evaluation                     Final evaluation.
Vertigo                                                 Yes              No              Yes               No
Headache                                             Yes              No              Yes              No
Tinnitus                                                 Yes              No              Yes              No
Nausea                                                 Yes              No              Yes              No
Fatigue                                                 Yes              No              Yes              No
Drowsy/sleepy                                      Yes              No              Yes              No
Sensitivity to light                                  Yes              No              Yes              No
Sensitivity to noise                                Yes              No              Yes              No
Ante grade amnesia                              Yes              No              Yes              No
Retro grade amnesia                             Yes              No              Yes              No

Additional findings/comments:

This concussion check list should be used not only for the initial evaluation but for each subsequent follow up assessment. A person should not be allowed to return to regular work or schedule if he is still experiencing any of these symptoms.

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Concussion Check List