Concussion Form

CONCUSSION INFORMATION

Name

Phone/Mobile

Date of concussions

How many concussions have been diagnosed by a medical professional?

What activity/sport did the concussion occur in?

What type of treatment was given for last concussion?

Duration of your last concussion?

What were the main symptoms after your last concussion?

Was dizziness a symptom of any of your concussions?

Yes

How long were you out before you were able to return to your sport?

What type of tests were completed before you were cleared from your concussions?

MYMRI