Classroom Concussion Assessment Form
ADVERTISEMENT
1
2Class/Period: __________________
Instructor: ____________________
Classroom Concussion Assessment Form
Name: ____________________________________________
Date: ___________ Time: __________
instructions to the Student:
instructions to the educator:
Read the symptoms in the left-hand column. For
Use the student’s responses to the following
each symptom, circle one answer in the center
questions to devise in-class, symptom-based
column. Be honest and do not skip any questions.
accommodations. Refer back to Concussions in
Then, answer the question at the bottom of this page.
the Classroom for more specific explanations of
Give the sheet to your educator once complete.
the accommodations.
Symptoms
circle one in each row
accommodations
Headache
none mild moderate severe
- Mild/moderate: Allow
Dizziness/balance problems
none mild moderate severe
classroom participation
Feeling sick to stomach (nausea)
none mild moderate severe
- Avoid symptom triggers
Tiredness/drowsiness
none mild moderate severe
- If severe, refer to nurse/parent
Symptoms
circle one
accommodations
Sensitivity to light
no
yes
- Move away from windows
- Dim lights/draw shades
- Allow sunglasses/hat in class
Sensitivity to noise
no
yes
- Remove from loud environments
- Reduce classroom noise
- Avoid headphones and loud music
Feeling mentally foggy
no
yes
- Give breaks between tasks
- Simplify tasks
Difficulty concentrating on
no
yes
- Shorten task duration
schoolwork
- Give breaks between tasks
Difficulty paying attention
no
yes
- Front room seating
to teacher
- Work/test in quiet room
Difficulty remembering
no
yes
- Provide class notes
- Provide memory aids
- Use alternative testing methods
Difficulty staying organized
no
yes
- Use agenda/planner for schedule and
due dates
- Check comprehension of instructions
- Use “to-do” lists and checklists
What tasks in school are most difficult for you? Please write specific examples.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical