ImPACT Concussion Management Program
Clinical Protocol and Health History
Name / ID:___________________________________
Date of Evaluation: ____________________________
Handedness:________ Education Level:___________
School ______________________________________
Date of Birth: ____________________
Referral Source:___________________
Baseline? Y / N___________________
ATC____________________________
History of Current Injury:
Date of Concussion: _____________Sport played, practice or game: _______________________________
Position: ______________________________________________________________________________
Mechanism of Injury : ___Head-head ___Head-ground ___Head-Body Part _____Other: _____________
Region of head: _____R / L Front, _____R / L Temp, _____R / L Parietal, _____R / L Occip
Mouthguard? Y / N
Describe: ________________________________________(boil & bite, vac, multi)
Injury description: ______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Returned to Play? Y / N __________________________________________________________________
Hospital? Y / N___________ CT / MRI ? Y / N _______When?___________ Where?________________
Immediate Symptoms
Yes
No
Present Symptoms
Duration/Description
Yes
No
Description
LOC
min
RGA
min
min
min
min
AGA
Disorentation
min
hrs
min
Top RF LF RT LT RO LO Gen
Headache
_____
/10
Top RF LF RT LT RO LO Gen
hrs
hrs
Throb/press/dull
Throb/press/dull
Worse in AM / PM
Worse w/ cog/ phys exert
Worse in AM / PM
/10
Worse w/ cog/ phys exert
Throb / press / dull
Throb / press / dull
Nausea
hrs
hrs
Vomiting
hrs
hrs
Dizziness
min
min
Balance Problems
hrs
hrs
Motor Problems
hrs
hrs
Numbness/Tingling
hrs
hrs
Fatigue
hrs
hrs
Visual Changes
hrs
hrs
Sensitivity to Light
min
min
Sensitivity to Noise
hrs
hrs
Emotionality
hrs
hrs
Irritability
hrs
hrs
“Fogginess”
hrs
hrs
Attn/Concentration
Short-term
Memory
hrs
hrs
hrs
hrs
Slowed Down
hrs
hrs
Hyposomnia
hrs
hrs
Hypersomnia
hrs
hrs
Drowsiness
Other:
hrs
hrs
hrs
hrs
Medical / Psychiatric History
Any hospitalizations/sports injuries? Y / N _____________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Claustrophobia? Y / N
History of concussion? Y / N
# of diagnosed concussions:________
# w/in the last 3 months:______
# with LOC:____________________
# w/in the last 3 months:______
# with RGA:____________________
# w/in the last 3 months:______
# with AGA:____________________
# w/in the last 3 months;______
# with Confusion:________________
# w/in the last 3 months:______
Description of previous concussions:________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Migraines? Y / N
Who: _________________________________
Seizure DO/Epilepsy? Y / N
Who:__________________________________
Depression / Anxiety? Y / N
Who: __________________________________
Therapy? Y / N
Who:__________________________________
AD/ Parkinson’s / other dementias? Y / N
Who:__________________________________
MS or other neurological? Y / N
Who:__________________________________
Substance abuse disorder? Y / N
Who:__________________________________
Average # of alcoholic drinks per week? _____________________________________________________
Current use of illicit substances_____________________________________________________________
Other Medical / Psychiatric: Y/N
Who:__________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Current medications? ___________________________________________________________________
Social / Educational History
Highest Education Completed/ Current Grade: ________________________________________________
Other Sports Played: _____________________________________________________________________
Occupation: ____________________________________________________________________________
LD? Y / N _________________________
ADD / ADHD? Y / N ___________________
Repeat / Skip grade? Y / N ______________
Speech Therapy? Y / N _________________
GPA _______________________________
SAT / ACT / PSAT______________________
Post-Injury Exertional Activity:
Physical:
Weights / Running / Practice / Games
[Symptoms worse with exertion?]
Cognitive: School Work / Job / Computer Work / Other Stresses
[Symptoms worse with exertion?]
Grades dropped?