Concussion Symptom Checklist

Learn about Concussion Symptom Checklists, then download our PDF template and use it for your practice!

By Matt Olivares on Jun 20, 2024.


Fact Checked by RJ Gumban.

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Concussion Symptom Checklist PDF Example
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What is a concussion?

Before we discuss what the Concussion Symptom Checklist is, let’s briefly discuss what concussions are first.

Concussions are a type of traumatic brain injury. It temporarily disrupts the brain’s functioning; those with it will look out of it and might be unresponsive for a few moments.

These brain injuries are caused by solid blows to a person’s head, strong to the point that the brain whips back and forth inside the skull. These are not limited to blows on the head, though. It can also be caused by solid blows to the body that are strong enough to make the head move back and forth rapidly, which shakes the skull and whips the brain back and forth, too.

These blows can be a strike from another person, something falling on their head, their head bumping something hard, or getting in a vehicular accident that causes whiplash.

Those with concussions will likely have the following signs and symptoms:

  • They might briefly lose consciousness
  • They will become dazed and confused
  • They will have trouble remembering what happened before the concussion
  • They will have a hard time following instructions
  • They will respond slowly when talked to, especially when asked questions
  • They might have temporary problems with balance and coordination
  • They will have a headache and a feeling of pressure in their heads
  • They might feel nauseated and vomit
  • They might have blurry or double vision
  • They might have an increased sensitivity to light and noises
  • There might be temporary changes in their personality and mood
  • They will feel fatigued
  • They might have trouble sleeping

Printable Concussion Symptom Checklist

Download this Concussion Symptom Checklist to accurately assess your patient’s concussion.

How do Concussion Symptom Checklists work:

A Concussion Symptom Checklist is a nifty clinical tool for healthcare professionals who specialize in handling patients with concussions. It’s also useful for particular non-clinical settings like sports and particular work that may involve accidents that harm a person’s head. It can even be used by parents or teachers in school who suspect that a child or student has a concussion because of an accident while playing or engaging in physical sports.

Our Concussion Symptom Checklist template is an adaptation of the checklist created by the Centers for Disease Control and Prevention. Their checklist is geared toward students, but we adjusted this to accommodate anyone, whether they’re still in school, a member of the workforce, an athlete, or a civilian who got into an accident.

Using our template is easy. All you need to do are the following:

  • Write down the full name of the person being evaluated
  • Indicate other information about the patient, like their date of birth and contact info
  • Indicate the date and time they suffered an injury that potentially gave them a concussion
  • Indicate where and how the injury occurred
  • Describe the injury
  • Tick where they are being evaluated (e.g., school, office, healthcare facility, other)
  • Tick all the concussion symptoms and signs that apply to the patient
  • Indicate if these signs and symptoms are present during 0, 15, and 30 minutes of observation, plus a certain number of minutes before leaving the evaluation site
  • Tick any danger signs they’ve noticed
  • Tick the resolution (e.g., the person returned to class/work/practice/their business, went home, referred to a healthcare facility for evaluation, scheduled for immediate testing)

After doing all these, the evaluator must indicate their full name at the bottom of the page, write their signature, indicate the date they evaluated the person with the potential concussion, and write down anything of note inside the Additional Comments section.

For non-healthcare professionals who refer people with potential concussions to healthcare professionals, they must ensure to pass these forms to the person they evaluated so they can show the checklist to healthcare professionals handling them for concussion testing.

Concussion Symptom Checklist example:

Now that you know the gist of concussions and have learned what to expect from our Concussion Symptom Checklist template, it’s time to acquaint you with it by showing you what it looks like when filled out.

You can fill this out with a pen if you print physical copies, or you can go paperless and simply engage with the interactive parts of the PDF file (the checkboxes can be ticked, and some blank spaces are fillable).

If you like what you see and believe this is a nifty tool for reporting and recording observable concussion signs and symptoms, feel free to download our Concussion Symptom Checklist PDF template!

Download this Concussion Symptom Checklist example: 

Concussion Symptom Checklist example

When is it best to use a Concussion Symptom Checklist?

At school or the workplace.

One of the great things about our Concussion Symptom Checklist template is that healthcare professionals and non-healthcare professionals can use it. It can also be used anywhere!

It can be used in schools by teaching staff who notice concussion symptoms in students, especially after they get into an accident while playing with friends, during PE, or because they were in a fight with other students.

It can be used in workplaces, especially where accidents can happen, like construction, delivery, police work, firefighting, factory work, and dock work, to mention a few.

During sporting events or training.

Athletes are at risk of sustaining concussions, especially those who engage in contact and combat sports. Suppose an athlete gets into an accident involving their heads (e.g., whiplash from getting tackled in American football, getting knocked out during an MMA fight, or botching a pro-wrestling maneuver). In that case, sports doctors and coaches should rush and check for any signs and symptoms of concussion and evaluate them using the checklist.

During clinical evaluations.

Suppose a patient presents themselves for a check-up to get assessed for the possibility of having a concussion. In that case, their assigned physicians can use this checklist at the beginning of the diagnostic process. It’s best to schedule them for a complete examination if they have even just one sign or symptom ticked on the checklist.

After getting diagnosed with a concussion, they should be scheduled for routine check-ups. The checklist can be used to monitor the signs and symptoms.

At home.

Speaking of monitoring signs and symptoms, part of the treatment for concussions is getting a lot of rest. A concussion patient’s loved ones can observe the patient at several points during the day and use the checklist to report anything of note to healthcare professionals during the next clinical visit.

What are the benefits of using a Concussion Symptom Checklist?

Standardized preliminary evaluation and early detection.

The great thing about concussion checklists is they list specific signs and symptoms that characterize the problem, so no matter what version of a concussion checklist you’re using, you will be looking for the same signs and symptoms.

Not only that, but checklists have the potential to detect concussions early. It doesn’t diagnose them, but the signs and symptoms are specific to concussions. When several signs and symptoms have been ticked, all that healthcare professionals need to do is conduct a series of tests that involve the assessment of cognition, neuropsychological testing, neurodiagnostic testing, and imaging tests to confirm the concussion and its severity.

It can help educational institutions and workplaces to make adjustments.

The Concussion Symptom Checklist can help inform teaching staff and human resources about the severity of a person’s concussion. This will help them make adjustments that accommodate any negative impacts the concussion left on the person and establish a learning or working environment that promotes their recovery.

It can help sports managers, doctors, and coaches determine if an athlete can return to training and competition.

Athletes who suffer concussions are not allowed to return to training or compete until they’ve been cleared. Sports managers, doctors, and coaches can use the Concussion Symptom Checklist to monitor concussed athletes over time. If their evaluations show that their signs and symptoms are no longer present and imaging tests have confirmed they’ve recovered, they can allow their concussed athletes to resume training and compete.

How can Carepatron help with concussion-related work?

Thanks for reading this guide about our Concussion Symptom Checklist template. We hope you have learned enough about concussions and the specific signs and symptoms associated with the brain injury. If you decide to use our checklist template, we hope it helps you detect concussion signs early and monitor your patients, loved ones, students, athletes, and workers easily.

While we still have you, we’d like to ask for your time to check more of the Carepatron platform if you haven’t. Our nifty features will convince you to consider us your number-one clinical documentation and general practice software. We won’t get into these features here, but we’d like to highlight one: our resource library.

This library houses a massive collection of clinical resources that cover numerous healthcare fields, topics, and practices! Another concussion-related guide and template is the SCAT5 (Sports Concussion Assessment Tool, Fifth Edition). This one is specifically geared toward assessing athletes, so if you specialize in assessing athletes, we recommend reading our guide and downloading our template! They’re free!

If you subscribe to use, you will gain access to our awesome EHR and storage system. This will allow healthcare professionals and the loved ones of concussed patients to share fully accomplished Concussion Symptom Checklists. Healthcare professionals will easily stay updated about the status of concussed patients at home. In turn, they can immediately update patients' loved ones after concussed patients attend a routine in-person check-up.

Your communication will be encrypted and protected. You can even store copies of the Concussion Symptom Checklist in a HIPAA-compliant manner with us and set who can access them besides you, your patients, and your patients’ loved ones.

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Who can use our Concussion Symptom Checklist template?
Who can use our Concussion Symptom Checklist template?

Commonly asked questions

Who can use our Concussion Symptom Checklist template?

Medical professionals who specialize in treating concussions, sports doctors, sports coaches and managers, patients' colleagues, students' teachers, parents, and guardians. Anyone can use our template since it reports and refers patients to healthcare professionals. It’s also a monitoring tool.

Can we use this checklist to diagnose concussions?

No. It’s more of a screening tool than a diagnostic tool. Further testing should help you diagnose patients. This tool should only help you identify the possibility of a concussion.

How often should this checklist be used when monitoring patients?

It depends on what has been discussed with the healthcare professional and the confirmed severity of the concussion. Some might use this one or twice a day. Some might be told to use the checklist every two days.

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