Sample Medical Assessment and Monitoring Form
This sample tool is intended to be completed by the Parents/Guardians after a concussion-related incident to communicate with the Principal/Designate about the results of the medical assessment by a Medical Doctor or Nurse Practitioner and/or the monitoring process by the Parents/Guardians.
Student Name:
Date of concussion-related incident:
Part 1 - Results of medical assessment (by a medical doctor and/or nurse practitioner)
No concussion diagnosed
- Student may resume full participation in learning and physical activity with no restrictions.
Concussion diagnosed
- Student will begin a medically supervised, individualized, and gradual Return to Learn and/or Return to Physical Activity plan.
Note: Attach relevant information provided by a medical doctor or nurse practitioner (e.g., notes from medical examination) regarding the student’s Return to School plan.
Medical doctor/nurse practitioner (providing examination):
Name:
Date:
Parent/Guardian
Signature:
Date:
Part 2 - Results of 48-hour monitoring period (at home and at school)
During this time the student can:
- continue to attend school and participate in learning activities
- resume participation in physical activity after 24 hours
No red flags and/or visible clues (signs) or symptoms observed and/or reported
- Student may continue full participation in learning and physical activity with no restrictions.
Red flags, visible clues (signs) and/or symptoms emerged
- seek a medical assessment by a medical doctor or nurse practitioner as soon as possible.
complete Part 1: Results of Medical Assessment and return the form to the school.
Parent/Guardian
Signature
Date
Comments
Note: If you wish to provide further information or have a question, contact the school Principal/Designate.