Suspected Concussion Report Form

Note: A PDF version of this document is also available.  In the case of any disagreement between this version and the PDF, the PDF will be considered authoritative.

Note: Activity leaders (ex. Captains, Most Caring Adult, Responsible Adults, coaches), can complete the online TUC Suspected Concussion Report Form.

Toronto Ultimate Club Suspected Concussion Report Form

Player Name:  _______________________________

Date of Birth:  ________________________________

Date & Time of Injury:  ________________________

Team Name:  _________________________________

League/Session/Event: _______________________

Game/Session Location:  _______________________

Injury Description:

Reported Symptoms (Check all that apply):

□ Headache

□ Feeling mentally foggy

□ Sensitive to light

□ Nausea

□ Feeling slowed down

□ Sensitive to noise

□ Dizziness

□ Difficulty concentrating

□ Irritability

□ Vomiting

□ Difficulty remembering

□ Sadness

□ Visual problems

□ Drowsiness

□ Nervous/anxious

□ Balance problems

□ Sleeping more/less than usual

□ More emotional

□ Numbness/tingling

□ Trouble falling asleep

□ Fatigue

Red Flag Symptoms (Check all that apply):  Call 911 immediately with a sudden onset of any of these symptoms

□ Headache that worsens

□ Can’t recognize people or places



Was 911 called?

□ Seizures or convulsions

□ Increasing confusion or irritability

□ Repeated vomiting

□ Weakness or numbness in arms/legs


□  Yes

□ Loss of consciousness

□ Persistent or increasing neck pain

□ Looks very drowsy/can’t be awakened

□ Unusual behavior change


□  No

□ Slurred speech

□ Focal neurological signs (e.g. paralysis, weakness, etc.)

Are there any other observable/reported systems?

□  Yes     □  No

If yes, what:  ________________________________________________________________________________

Is there evidence of injury to anywhere else on the body besides the head?

□  Yes     □  No

If yes, where:  _______________________________________________________________________________

Has this player had a concussion before?

□  Yes     □  No     □  Unsure     □  Prefer not to answer

If yes, how many:  ___________________________________________________________________________

Does this player have any pre-existing medical conditions?

□  Yes     □  No     □  Unsure     □  Prefer not to answer

If yes, please list:  ____________________________________________________________________________

Does this player take any medication?

□  Yes     □  No     □  Unsure     □  Prefer not to answer

If yes, please list:  ____________________________________________________________________________

I [name of trainer/coach/manager/captain completing this form],  ____________________________________ recommended to the player/player’s parent/guardian that the player sees a medical professional immediately.  A medical professional includes a medical doctor, family doctor, pediatrician, emergency room doctor, sports-medicine physician, neurologist or nurse practitioner.

Signature:  ___________________

Date:  _______________________

Role:  _______________________


PLEASE NOTE:  This form is to be completed by the team trainer/coach/captain in the event of a suspected concussion in any Toronto Ultimate (TUC) activity.  Once this form is complete, give one copy of this report to the player/player’s parent/guardian and the other to the TUC head offices.  EMAIL:  ed@tuc.orgPlayers/Player’s parents/guardians are to take this form to a medical professional immediately.

*Please review TUC’s Concussion Policy for the list of appropriate medical professionals for the diagnosis.