School Head Injury Form

Date   

Dear   Parent/Guardian First Name   Parent/Guardian Last Name ,

We regret to inform you that your child   Student's First Name   Student's Last Name   had a minor accident. The head of the child was bumped specifically the  exact part of head area. This accident happened on   Date of accident   at  Time of accidentAMPM   in the   Location/Area .

Below is the detailed explanation of what exactly happened:
1 

According to the school physician, these are the symptoms the student is having:
Headache   Bruising   Loss of consciousness   Cut/Abrasion   Loss of memory   Dizziness   Confused and disoriented   Nausea           VomitingWeakness   No symptoms   

The medical treatment or first aid we applied are the following:
2

Here are the recommendations of the physician:   
3   
4   
5   

If the child/student is experiencing any symptoms below, please go to the emergency room or call 911:
Increased headache intensity   Vomiting   Seizures   Dyspnea or Difficulty of breathing   Mild stroke symptoms      

If you have any questions, please call the school physician using the contact details below.


Physician's Signature   
Physician's First Name   Physician's Last Name   
Date Signed