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Athletic trainers, please complete the fields below to record your athlete's contact information and note the details associated with his or her injury, and then click the Submit button at bottom.

* Indicates required information
---------------------------------------- Patient Information ---------------------------------------- 
First Name * 
Last Name * 
Street Address 
City 
State 
Zip 
e-mail Address 
Phone * 
Date of Birth *  Calendar (mm/dd/yyyy)
Age * 
Sex * 
Organization or School Team * 
Uniform or Jersey Number 
Emergency Contact Name * 
Emergency Contact Phone * 
Referred to * 

If Other, please specify:

Physician Referral 1 
Physician Referral 2 
Physician Referral 3 
Follow up with * 
---------------------------------------- Injury History ---------------------------------------- 
Date of Injury *  Calendar (mm/dd/yyyy)
Time of Injury * 
Injury Area (Check all that apply) * 
Additional Injury Location Info * 

If Other, please specify:

Activity When Injury Occurred * 

If Other, please specify:

Injury Occurred During * 

If Other, please specify:

Surface * 

If Other, please specify:

Mechanism 
---------------------------------------- Examination and Vital Signs ---------------------------------------- 
Time of Exam 
Pulse 
Blood Pressure 
Respiration Rate 
Temperature 
---------------------------------------- Mild Traumatic Brain Injury ---------------------------------------- 
Point of Impact  
Memory of Events Before Concussion  
Memory of Events after Concussion  
Immediate Three-Word Recall 
Delayed Three-Word Recall 
Months in Reverse order  
Digits Backward 
---------------------------------------- Neurological Screening/Special Test ---------------------------------------- 
Headache 
Dizziness 
Balance Problems 
Nausea/Vomiting 
Pressure in Head 
Sensitive to Noise 
Visual Problems 
Numbness or Tingling Sensation 
Feeling Fatigued or Drowsy 
Feeling Fuzzy or Foggy 
Feeling Confused 
Attention Problems 
Cognitive Slowing 
Poor Concentration 
Poor Memory 
Irritability 
Feeling of Sadness 
Feeling of Nervousness 
More Emotional than Usual 
Total Symptom Score  
Speech 
Eye Motion/Pupils 
Romberg Test 
Tandem Romberg Test 
Gait Assessment 
Dynamic Visual 
Neurological Abnormalities 
---------------------------------------- SOAP Notes ---------------------------------------- 
Subjective 
Objective 
Assessment 
Plan 
Examiner Name and Title * 
Authentication * 

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