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Concussion Signs and Symptoms

Students Name: _____________________________________________ Students Grade: _______ Date/Time of Injury: _______________

Where and How Injury Occurred: (Be sure to include cause and force of the hit or blow to the head.) ____________________________________________


Description of Injury: (Be sure to include information about any loss of consciousness and for how long, memory loss, or seizures following the injury, or previous

concussions, if any. See the section on Danger Signs on the back of this form.) __________________________________________________________________




Use this checklist to monitor Just prior to
students who come to your oce
Appears dazed or stunned
with a head injury. Students should
Is confused about events
be monitored for a minimum of Repeats questions
30 minutes. Check for signs or Answers questions slowly
symptoms when the student rst Cant recall events prior to the hit, bump, or fall
arrives at your oce, fteen minutes Cant recall events after the hit, bump, or fall
later, and at the end of 30 minutes. Loses consciousness (even briefly)
Shows behavior or personality changes
Students who experience one or Forgets class schedule or assignments
more of the signs or symptoms of
concussion after a bump, blow, or PHYSICAL SYMPTOMS
Headache or pressure in head
jolt to the head should be referred
Nausea or vomiting
to a health care professional with
Balance problems or dizziness
experience in evaluating for
Fatigue or feeling tired
concussion. For those instances
Blurry or double vision
when a parent is coming to take the
Sensitivity to light
student to a health care professional, Sensitivity to noise
observe the student for any new or Numbness or tingling
worsening symptoms right before Does not feel right
the student leaves. Send a copy of
this checklist with the student for the COGNITIVE SYMPTOMS
health care professional to review. Difficulty thinking clearly
Difficulty concentrating
Difficulty remembering
Feeling more slowed down
Feeling sluggish, hazy, foggy, or groggy

To download this checklist in Spanish, Irritable
please visit:
Para obtener una copia electrnica de
More emotional than usual
May 2010

esta lista de sntomas en espaol,

por favor visite:

Danger Signs: Additional Information About This Checklist:
Be alert for symptoms that worsen over time. The This checklist is also useful if a student appears to have
student should be seen in an emergency department sustained a head injury outside of school or on a previous
right away if s/he has: school day. In such cases, be sure to ask the student
about possible sleep symptoms. Drowsiness, sleeping
r One pupil (the black part in the middle of the eye)
more or less than usual, or diculty falling asleep may
larger than the other
indicate a concussion.
r Drowsiness or cannot be awakened
r A headache that gets worse and does not go away
To maintain condentiality and ensure privacy, this
r Weakness, numbness, or decreased coordination
checklist is intended only for use by appropriate school
r Repeated vomiting or nausea
professionals, health care professionals, and the
r Slurred speech students parent(s) or guardian(s).
r Convulsions or seizures
r Diculty recognizing people or places For a free tear-o pad with additional copies of this
r Increasing confusion, restlessness, or agitation form, or for more information on concussion, visit:
r Unusual behavior
r Loss of consciousness (even a brief loss of
consciousness should be taken seriously)

Resolution of Injury:
__ Student returned to class
__ Student sent home
__ Student referred to health care professional with experience in evaluating for concussion

SIGNATURE OF SCHOOL PROFESSIONAL COMPLETING THIS FORM: _________________________________________

TITLE: ____________________________________________________________________________


U.S. D epartment of H ealtH anD H Uman S erviceS

For more information on concussion and to order additional
centerS for DiSeaSe control anD prevention
materials for school professionals FREE-OF-CHARGE,