DAMIEN HIGH SCHOOL
HEAD INJURY INSTRUCTION SHEET
Athletes Name: ________________________________ Sport: ________________ Date of Injury: _______________
This form is to be given to an adult who accompanies the patient home and can monitor the patient for the appearance of
worrisome signs and symptoms.
Your son has suffered a mild head injury (Concussion) in his participation in sports or school activities. This form will provide
you some information about what to expect and what to watch out for. By California State Law (CIF Bylaw 313/ AB 25) your
son was removed from participation and is not able to return to play for a minimum of 24 hours with a release note from their
physician (MD or DO). All head injuries MUST be seen by an MD or DO ONLY! Chiropractors, Nurse Practitioners, and
Physician Assistants are NOT authorized to release an athlete back to play after suffering a head injury. Do not participate in
practice or competition until the doctor has released you to return to play. Submit the Doctors note for return to play to the
Athletic Trainer before you report back to practice.
It Is Common To Experience:
 Low-grade headache
 Dizziness or lightheadedness
 Nausea
 Poor attention span
 Memory problems
 Fatigue
 Low frustration tolerance and increased irritability
 Bright light sensitivity
 Ringing in the ears
 Sensitivity to loud noises
 Anxiety
 Depression
 Slow reaction times
 Difficulty sleeping
DO NOT TAKE ANY PAIN MEDICATION UNLESS THE DOCTOR HAS PRESCRIBED IT. It may disguise an increase in
headache which is a symptom needing immediate medical attention.
Symptoms Of An Emergency - Go to the Emergency Room Immediately if you Experience any of the Following:
 Inability to stay away or arouse from sleep
 Increased confusion
 Worsening Headache
 Vomiting
 Stumbling and uncoordinated
 Weakness in the arms or legs
 Unintelligible speech
 Dramatic personality change
 Convulsions “fits”
 Blurred or double vision
If you have any questions, feel free to contact us!
Jessica Truax, M.Ed, ATC
Head Athletic Trainer / Sports Medicine Director
jtruax@Damien-hs.edu
909-596-1946 ext 274
Alyssa Wheeler, MS, ATC
Full Time Athletic Trainer
wheeler@Damien-hs.edu
Damien Concussion Guidelines/ Protocols
Updated July 2014
A new law has passed in the State of California effective January 1, 2012 (CIF Bylaw 313/ AB25) that is
recognized and followed by the Damien High School Sports Medicine Staff. This is our Return to Play
Guidelines after an athlete has suffered a concussion.
1. Evaluation of the Injury
Certified Athletic Trainers (ATs) are qualified health care professionals for the evaluation and
treatment of athletic illnesses and injuries. We will evaluate your son’s emotional state, cognitive
abilities, cranial nerves, and proprioceptive abilities through a series of tests. If we believe your son has
a concussion, even a very mild concussion (“Bell rung”) they are removed from play immediately by
law for a minimum of 24 hours, must see a Medical Doctor (Preferred with a Background in Concussion
Management), then must see the AT to begin the Return to Play Protocol. The AT will give the final
consent to release the athlete back to play.
2. Parents are notified verbally and given a concussion guideline sheet with the medical doctor
communication form. This form provides the MD or DO of our findings and allows them to
communicate with us when the athlete may return to play, or need to return to the doctor for follow
up.
3. Athletes ARE NOT ALLOWED TO PARTICIPATE for a minimum of 24 hours and MUST HAVE A
DOCTORS NOTE clearing them to go back to play. The note must be turned into the DHS Athletic
Trainer before they are released to play. The Doctors note DOES NOT mean an immediate return to
play. The doctor’s note will begin the Return to Play Protocol. They must be evaluated and returned to
play with the following progression assigned by the Athletic Trainer. This progression usually takes a
minimum of 4 days after the doctor’s release date, but can last up to several weeks based on the
severity of the symptoms.
a. Doctor’s note is turned in
b. If the Patient/ Athlete is completely asymptomatic (no symptoms) we will put them through a
series of cognitive and agility drills to check their neurological state and increase the blood
pressure. If concussion symptoms return due to physical exertion, the athlete is stopped
immediately and will be tested again in a minimum of 24 hours. This indicates that the
concussion is still present. They will be retested when they are asymptomatic.
c. If the Patient/ Athlete completes the agility drills without any symptoms, the next day they will
return to the Athletic Trainer in their uniform and practice gear. Another series of agility drills
is completed as well as conditioning with the team WITHOUT CONTACT if the agility drills do
not bring on any symptoms. If symptoms return the athlete is removed for a minimum of 24
hours and retested again when they are asymptomatic.
d. If the athlete has complete the 2 phases symptom free, then they will be allowed to practice
with the team WITHOUT CONTACT and are periodically checked on by the AT. If no symptoms
are brought on, then the athlete is allowed to return to full participation.
4. Coaches will be informed of the status of the athlete and are not allowed to let the athlete participate
until they have received confirmation from the athletic training staff.
5. Concussion release can ONLY be given by an MD or DO. Chiropractor’s, Nurse Practitioner’s, and
Physician Assistant’s are NOT ALLOWED to clear an athlete after suffering a concussion by California
State Law.
6. Parents no longer have the right to override the Athletic Trainer’s diagnosis in order to allow their
child to continue to play without seeing a physician by California State Law.
Damien High School Sports Medicine
Doctor / ATC Communication Form
To Be Completed By the ATC:
Today’s Date: ________________
Date of Injury: _______________
Athlete’s Name: ___________________________________ Age: _____ Sport: __________________
Diagnostic Impression: __________________________________________________________________
Notes:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Treatment Received:
__________________________________________________________________________________________
__________________________________________________________________________________________
Recommendation(s):
__________________________________________________________________________________________
Thank You,
______________________________
Jessica Truax, M.Ed, ATC
626-695-3704 Cell
JTruax@damien-hs.edu
____________________________
Alyssa Wheeler, MS, ATC
760-987-3463 Cell
Wheeler@damien-hs.edu
To Be Completed By The Doctor:
Diagnosis: ____________________________________________________________________________
Recommendations for Treatment:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
0 Cleared to Play Date of Release: _________________________
0 Cleared to Play with the following restrictions: ___________________________________________________
0 Not Cleared: _____________________________________________________________________________
***Note: Only an MD or DO can release an athlete back to play after suffering a head injury by
California State Law. Please provide your credentials ***
_____________________________________________________________
Physician’s Signature (MD or DO)
Physician Stamp
Date: ______________