On-Field Concussion Evaluation Form
Use this On-Field Concussion Evaluation Form to quickly and comprehensively assess a player immediately after a suspected concussion incident on the field.
Player Name
*
First Name
Last Name
Team
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Evaluator Name
*
First Name
Last Name
Observable Signs (select all that apply)
*
Loss of consciousness
Disorientation or confusion
Unsteady gait or balance issues
Blank or vacant stare
Delayed response to questions
Other
Player-Reported Symptoms (select all that apply)
*
Headache
Nausea or vomiting
Dizziness
Sensitivity to light or noise
Confusion or feeling 'foggy'
Other
Orientation Assessment (ask the player and record their answers)
*
Memory Recall (ask the player to recall events before and after the incident)
*
Balance/Coordination Check (describe any observed difficulties)
Evaluator Notes / Recommendations
Submit Evaluation
Should be Empty: