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
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Player Name: _______________________________ |
Date of Birth: ________________________________ |
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Date & Time of Injury: ________________________ |
Team Name: _________________________________ |
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League/Session/Event: _______________________ |
Game/Session Location: _______________________ |
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Injury Description: |
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Reported Symptoms (Check all that apply): |
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□ Headache |
□ Feeling mentally foggy |
□ Sensitive to light |
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□ Nausea |
□ Feeling slowed down |
□ Sensitive to noise |
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□ Dizziness |
□ Difficulty concentrating |
□ Irritability |
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□ Vomiting |
□ Difficulty remembering |
□ Sadness |
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□ Visual problems |
□ Drowsiness |
□ Nervous/anxious |
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□ Balance problems |
□ Sleeping more/less than usual |
□ More emotional |
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□ Numbness/tingling |
□ Trouble falling asleep |
□ Fatigue |
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Red Flag Symptoms (Check all that apply): Call 911 immediately with a sudden onset of any of these symptoms |
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□ Headache that worsens |
□ Can’t recognize people or places |
Was 911 called? |
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□ Seizures or convulsions |
□ Increasing confusion or irritability |
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□ Repeated vomiting |
□ Weakness or numbness in arms/legs |
□ Yes |
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□ Loss of consciousness |
□ Persistent or increasing neck pain |
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□ Looks very drowsy/can’t be awakened |
□ Unusual behavior change |
□ No |
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□ Slurred speech |
□ Focal neurological signs (e.g. paralysis, weakness, etc.) |
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Are there any other observable/reported systems? |
□ Yes □ No |
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If yes, what: ________________________________________________________________________________ |
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Is there evidence of injury to anywhere else on the body besides the head? |
□ Yes □ No |
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If yes, where: _______________________________________________________________________________ |
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Has this player had a concussion before? |
□ Yes □ No □ Unsure □ Prefer not to answer |
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If yes, how many: ___________________________________________________________________________ |
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Does this player have any pre-existing medical conditions? |
□ Yes □ No □ Unsure □ Prefer not to answer |
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If yes, please list: ____________________________________________________________________________ |
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Does this player take any medication? |
□ Yes □ No □ Unsure □ Prefer not to answer |
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If yes, please list: ____________________________________________________________________________ |
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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. |
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Signature: ___________________ |
Date: _______________________ |
Role: _______________________ |
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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.org. Players/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.