Signs and symptoms of concussion
Every child who gets a head injury should be seen by a doctor as soon as possible.
Athletes who experience one or more of the signs and symptoms listed below, or who report that they just “don't feel
right,” after a bump, blow, or jolt to the head or body may have a concussion.
Signs observed by Coaching Staff
 Appears dazed or stunned (such as glassy
eyes)
 Is confused about assignment or position
 Forgets an instruction or play
 Is unsure of score or opponent
 Moves clumsily or poor balance
 Answers questions slowly
 Loses consciousness (even briefly)
 Shows mood, behavior, or personality
changes
 Can’t recall events prior to hit or fall
 Can’t recall events after hit or fall
Symptoms reported by Athlete
 Headache or “pressure” in head
 Nausea or vomiting
 Balance problems or dizziness
 Double or blurry vision
 Sensitivity to light or noise
 Feeling sluggish, hazy, foggy, or groggy
 Concentration or memory problems
 Confusion
 Does not “feel right” or is “feeling down”
Red flags to seek Emergent Care in Recovery Process:
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Worsening headaches
Inability to recognize
people/location
Repeated vomiting
Increased confusion
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Increased irritability
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Seizures
Change in state of
consciousness
Slurred speech
Unusual behavior
change
Having trouble walking
**From Heads Up Concussion in Football website
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Focal neurologic signs
Difficulty in being
awakened/overly drowsy
Neck Pain
Numbness/weakness in
extremities
Return to Play Program
For the safety of all players with a physician confirmed concussions or “inconclusive” concussion, this form must be
completed and returned to the Commissioner and/or Team Coach before the player has clearance to return to play.
Below are five gradual steps that you and the health care professional should follow to help safely return
an athlete to play. Remember, this is a gradual process. These steps should not be completed in one day,
but instead over days, weeks, or months.
BASELINE: Athletes should not have any concussion symptoms. Athletes should only progress to the
next step if they do not have any symptoms at the current step.
Physician clearance required to begin Step 1
Date:
Physician Signature: _______________________
Date & Signature of Parent
Date:
Parent signature: __________________________
STEP 1: Light aerobic exercise
Begin with light aerobic exercise only to increase an athlete’s heart
rate; about 5 to 10 minutes on an exercise bike, walking, or light
jogging. No weight lifting at this point.
Date:
Parent signature:
________________________
STEP 2: Non-contact moderate physical and/or aerobic exercise
Activities to increase an athlete’s heart rate with body or head
movement; moderate jogging, brief running, moderate-intensity
stationary biking, moderate-intensity weightlifting
Date:
Parent signature:
________________________
STEP 3: Non-contact training drills
Heavy non-contact physical activity, such as sprinting/running, highintensity stationary biking, regular weightlifting routine, non-contact
sport-specific drills (in 3 planes of movement).
Physician clearance required to begin Step 4
Date:
Physician Signature: _______________________
Date:
Parent signature:
________________________
Date & Signature of Parent
Date:
Parent signature: __________________________
STEP 4: Full contact practice
Athlete may return to practice and full contact (if appropriate for the
sport) in controlled practice.
STEP 5: Return to game play
Athlete may return to competition.
**Parent is comfortable with their child returning to game play.
Date:
Parent signature:
________________________
Date:
Parent signature:
________________________
If an athlete’s symptoms come back or she or he gets new symptoms when becoming more active at any
step, this is a sign that the athlete is pushing him or herself too hard. The athlete should stop these
activities and the athlete’s physician should be contacted. After more rest and no concussion symptoms,
the athlete should begin at the previous step.
**Some materials provided by CDC Heads Up Concussion in Youth Sports Fact Sheet for Coaches
Suspected Concussion/Return to Play Instructions
It is suspected that your child has a concussion. All players suspected of a concussion must URGENTLY consult
with a physician. For the safety of our players, it is Westman Youth Football’s policy to require a player with a
suspected concussion to immediately consult with a physician and return the signed “Concussion Diagnosis” to the
Commissioner and/or Team Coach. If a concussion has been diagnosed or remains “inconclusive”, the player must follow
and complete both the “Concussion Diagnosis” and the “Return to Play Program” found on the reverse side of this form. If
the physician does not diagnose a concussion, this signed portion of the form should be returned to the Commissioner
and/or Team Coach and the player has immediate clearance to play.
Concussion Diagnosis
Name of Athlete: ______________________________
Date of Birth: _______________________
Date assessed: ______________________________
This player has a concussion (check one):
YES___
NO___
Inconclusive___
Physician Signature: _______________________________________________
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Concussion “Return to Play Program” Instructions
For players with a physician confirmed concussion or “inconclusive” concussion.
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There are six incremental stages for a player to clear and remain symptom-free. For questions regarding the
symptoms, steps and safe return to play, please further consult with a medical professional.
Physician signature and date is required upon completion of “baseline” step and Step 3.
Parental signature and date is required after EACH step, verifying safe completion.
Progression between each step should take a minimum of 24 hours; move forward ONLY when symptom-free.
If symptoms reappear during any step, the player should stop the activity immediately and rest for 24 hours.
Once they are no longer experiencing symptoms, they should drop down to the previous step, and try to progress
again.
Please return the signed “Return to Play Program” form to the Commissioner and/or Team Coach indicating that
clearance of all Steps have been completed, and authorized by both parent(s) and physician where indicated.
Even if the player has safely completed all six steps and has clearance to return to game play, if concussion
symptoms reoccur upon return, the player should immediately STOP and see their physician.
It’s important that athletes, their families and coaches understand the seriousness of concussion. This can be
difficult as it is not an obvious injury. Symptoms may take hours or days to develop, and when they do, they
are essentially “invisible”. Unlike an ankle injury in which the obvious pain prompts one to rest, a brain injury is
not as obvious, but it still calls for rest in order to heal.
Returning to play before the injury has healed can not only prolong the injury, but also put a person at risk for
later and life threatening concussions. Time away from sport is important to give the brain time to rest and
recover, but also to reduce the risk of re-injuring oneself while the brain is still very vulnerable. If another
concussion is experienced before the first has had time to heal, the second concussion puts the individual at
risk for long-term problems, or could even be fatal.
For further reference:
http://www.cdc.gov/concussion/HeadsUp/youth.html
http://www.cdc.gov/concussion/HeadsUp/pdf/Football_Fact_Sheet_Coaches-a.pdf