SCHOOLRECOMMENDATIONSFOLLOWINGCONCUSSION
PatientName:____________________________________________
DateofBirth:______________________________________
DateofEvaluation:_______________________________________Referredby:________________________________________
DurationofRecommendations:1week 2weeks
4weeks
Untilfurthernotice
Thepatientwillbereassessedforrevisionoftheserecommendationsin___________weeks.
Thispatienthasbeendiagnosedwithaconcussion(abraininjury)andiscurrentlyunderourcare.Pleaseexcusethe
patientfromschooltodayduetothemedicalappointment.Flexibilityandadditionalsupportsareneededduring
recovery.Thefollowingaresuggestionsforacademicadjustmentstobeindividualizedforthestudentasdeemed
appropriateintheschoolsetting.Feelfreetoapply/removeadjustmentsasneededasthestudent’ssymptoms
improve/worsen.
__________________________________________________________________________________________
Attendance
______ Noschoolfor_____schoolday(s) ______ Attendanceatschool_____daysperweek ______ Fullschooldaysastoleratedbythestudent
______ Partialdaysastoleratedbythestudent Breaks
______ Allowthestudenttogotothenurse’s
officeifsymptomsincrease
______ Allowstudenttogohomeifsymptomsdo
notsubside
______ Allowotherbreaksduringschooldayas
deemednecessaryandappropriateby
schoolpersonnel
VisualStimulus
AudibleStimulus
______ Allowstudenttowearsunglasses/hatinschool ______ Lunchinaquietplacewithafriend
______ Pre‐printednotesforclassmaterialornotetaker ______ Avoidmusicorshopclasses
______ Limitedcomputer,TVscreen,brightscreenuse ______ Allowtowearearplugsasneeded
______ Reducebrightnessonmonitors/screens ______ Allowclasstransitionsbeforebell
______ Changeclassroomseatingasnecessary
Workload/Multi‐Tasking
Testing
______ Reduceoverallamountofmake‐upwork,class
______ Additionaltimetocompletetests
workandhomework
______ Nomorethanonetestaday
______ Prorateworkloadwhenpossible ______ Nostandardizedtestinguntil______________
______ Reduceamountofhomeworkgiveneachnight
______ Allowforscribe,oralresponse,andoral
deliveryofquestions,ifavailable
PhysicalExertion
AdditionalRecommendations
______ Nophysicalexertion/athletics/gym/recess
__________________________________________________________
______ Walkingingymclassonly
__________________________________________________________
______ Beginreturntoplayprotocolasoutlinedby
__________________________________________________________
returntoactivityform __________________________________________________________
CurrentSymptomsList(thestudentisnotingthesetoday)
______
______
______
Headache
Nausea Dizziness
______
______
______
Visualproblems ______
Balanceproblems ______
Sensitivitytolight ______
Studentisreportingmostdifficultywith/in
Sensitivitytonoise Feelingfoggy
Difficultyconcentrating
______
______
______
Memoryissues
Fatigue
Irritability
______
Allsubjects
______
Reading/Languagearts
______
ForeignLanguage ______
Math
______
Science ______
Music ______
History ______
UsingComputers
______
Focusing
______
Listening
Other:________________________________________________________
I,___________________________________________,givepermissionfor
Dr.XXXXXXXXXtosharethefollowinginformationwith
mychild’sschoolandforcommunicationtooccur
betweentheschoolandDr.XXXXXXXforchangestothis
__________________________________________________________
plan
XXXXXXXXXXXX,MD
_______________________________________________________________________
XXXXXXXXXXXXXXXXXXXX
ParentSignatureDate
Office(XXX)XXX‐XXXXFax(XXX)XXX‐XXXX
This form may be duplicated or changed to suit your needs and your patients’ needs.