physician concussion evaluation form - Jackson Memorial High School
physician concussion evaluation form - Jackson Memorial High School
physician concussion evaluation form - Jackson Memorial High School
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PHYSICIAN CONCUSSION EVALUATION FORM<br />
ImPACT Testing<br />
In the sports of Football, Cheerleading, Gymnastics, Soccer, Field Hockey, Wrestling, Ice Hockey and Lacrosse we require pre-season<br />
baseline and post-<strong>concussion</strong> neuro-cognitive testing using the ImPACT ® (Immediate Post Concussion Assessment and Cognitive<br />
Testing) software program to assist in the management of head injuries. The 20-minute program is set up in a “video-game” <strong>form</strong>at. It<br />
tracks neuro-cognitive in<strong>form</strong>ation such as memory, reaction time, brain processing speed and concentration. We conduct a postconcussive<br />
test when the athlete is asymptomatic and continue to test the athlete until their scores return to normal. Please note that<br />
this program is used only as a tool in making return to play decisions. Additional in<strong>form</strong>ation about ImPACT ® can be found at<br />
www.impacttest.com.<br />
Thank you for your assistance. If you have any questions, please feel free to contact us at your earliest convenience.<br />
Sincerely,<br />
Scott V. Royer, MA, ATC<br />
Athletic Trainer<br />
<strong>Jackson</strong> <strong>Memorial</strong> <strong>High</strong> <strong>School</strong><br />
Nicolle K. Figaro, MSEd, ATC<br />
Athletic Trainer<br />
<strong>Jackson</strong> Liberty <strong>High</strong> <strong>School</strong><br />
For the Physician: Please indicate your diagnosis and treatment plan below. Please note that<br />
return to sports clearance that is inconsistent with our <strong>concussion</strong> policy may not be accepted<br />
and these matters will be referred to our school <strong>physician</strong>. Thank you.<br />
Date: ____________<br />
Physician’s Diagnosis:___________________________________________<br />
Return to Activity<br />
Please check one:<br />
___I agree the athlete is cleared for unrestricted sports once he/she meets the criteria outlined in this policy. This includes:<br />
1. Asymptomatic (with no use of medications to mask headache or other symptoms)<br />
2. Completion of Zurich Activity Progression. This may begin once the athlete is asymptomatic and medically cleared.<br />
3. ImPACT scores return to within normal limits of baseline (if applicable).<br />
4. Carrying a full academic load without remediation (if applicable).<br />
___I have different recommendations beyond the above recommendations (please specify):<br />
___The athlete is to see me again before beginning any physical activity.<br />
Additional comments:<br />
Physician’s name (please print): ____________________________________________<br />
Address: _________________________________________________________________<br />
Phone: ___________________________________________________________________<br />
References:<br />
1<br />
McCrory Physician’s et al. Consensus Signature: Statement on __________________________________________________<br />
Concussion in Sport: The 3 rd International Conference on Concussion in Sport. Journal of Athletic Training, 2009: 44(4) : 434-<br />
448.<br />
2<br />
NJSA 18A:40-41.3 Model Policy and Guidance for the Prevention and Treatment of Sports Related Concussions. NJ Department of Education, March 2011.
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