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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 Learning (RTL) Plan and Return to Physical Activity (RTPA) Plan.

For more information, consult the Sample Home Concussion Management Form (Return to School 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: