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Certified ImPACT Consultant
CONCUSSION MEDICAL EVALUATION FORM
To Be Completed by Medical Personnel and returned to Think Head First CIC
This athlete is being referred for evaluation following a concussion. There are concerns about his/her return to sport at this time. Please evaluate the athlete’s readiness to return to sport based on the description of their sport listed below. As part of your evaluation, please complete the SCAT exam as well as a neurological examination and any other medical tests that you feel are appropriate. The athlete will be required to return this completed form and attached results to the THF CIC prior to ImPACT testing to be allowed to participate.
Athlete Name: ____________________________ Date: _______________
Athlete DOB: _____________________
Neurological Examination Normal ______ Abnormal ______
If Abnormal please describe:
SCAT Examination Normal ______ Abnormal ______
If Abnormal please describe:
Any Additional Comments:
If additional procedures/tests done, please describe results below (ie., CT/MRI):
In your medical opinion, is this athlete ready to return to progression into sport/competition based on the description listed below? Yes _________ No __________
___________________________ _____________ _______________________
Signature Phone Date
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Name Printed Email
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Address
Soccer/Futbol
Specific physical demands and risks involved with the sport:
Soccer requires a combination of continuous stop and go running mixed with varied to full speed sprinting throughout a competition. It demands constant technical foot skills as well as the use of various parts of the body including the head. It is a contact sport with contact coming from tackling, heading, collisions and inadvertent body contact from contesting of 50-50 balls. Concussions are most common from head to head contact, elbow to head contact and/or head to ground contact following a collision or tripping violation.
Melinda Roalstad, PAC 435 336-4403 Wain Allen, MD
Coalville Health Center
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