Sample Medical Concussion Assessment Form

The Medical Assessment Form is provided to a student that demonstrates or reports concussion signs and or symptoms. For more information consult the Sample Tool to Identify a Suspected Concussion.

Student Name:
Date:

The student must be assessed as soon as possible by a medical doctor or nurse practitioner. In Canada, only medical doctors and nurse practitioners are qualified to provide a concussion diagnosis. In rural or northern regions, a nurse with pre-arranged access to a medical doctor or nurse practitioner may be used to assess the suspected concussion. Prior to returning to school, the parents/guardians must inform the school principal of the results of the medical assessment.

Results of the Medical Assessment

My child/ward has been assessed and a concussion has not been diagnosed and therefore may resume full participation in learning and physical activity without any restrictions.
My child/ward has been assessed and a concussion has been diagnosed and therefore must begin a medically supervised, individualized, and gradual Return to School (RTS) and Return to Physical Activity (RTPA) Plan.
My child/ward has been assessed and a concussion has not been diagnosed but the assessment led to the following diagnosis and recommendations:
Comments:

Medical doctor/nurse practitioner

Name:
Phone Number:

Parent/Guardian

Signature:
Date: