Orleans Central Supervisory Union
Head Injury Assessment Form
Student_____________________________________________ dob ___________ Date________________ Time_____________
Evaluated:  at the scene  In the Health Office, if so…..  ambulatory or  assisted, how? _______________________________________
Was there loss of consciousness?
 yes
 no
Chief complaint: _______________________________________________________________________________________________
__________________________________________________________________________________________________________________
How did the injury occur? ____________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Vital signs:
Time
Temp.
Pulse
Resp.
BP
Pupils Equal, Round, Reactive to light Accommodation (PERRLA)
Pupil size (draw)
Right___________
Left ____________
 yes  no
Strong, equal, bilateral hand grips
Strong equal, bilateral pedal strength
Headache
Nausea / vomiting
Vision impaired
Dizziness
 yes
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 no
GLASGOW COMA SCALE - helps to describe the victim’s level of consciousness and possible severity of brain injury
Eye opening response (circle)
Spontaneously
To voice
To pain
None
4
3
2
1
Verbal Response
Alert +Oriented x 3
Confused, disoriented
Inappropriate words
Moans, incomprehensible
None
TOTAL SCORE:__________________
Motor Response
5
4
3
2
1
Obeys Commands
Purposeful movement to pain
Withdraws from pain
Abnormal (spastic) flexion
Abnormal (rigid)extension
None
(3-8 = severe; 9-12 = moderate; 12-15 = mild)
6
5
4
3
2
1
Treatment: _____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Comments: ____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Parent notified at ____________
 by phone
 phone message  other _____________________________________
Disposition: __________________________________________________________________________________________________________
Signature________________________________________________ title/position ___________________________