EMRG Concussion Assessment Form

    Red Flags (Any yes answer - Immediate call for Ambulance)

    Neck Pain or TendernessDouble VisionWeakness or Tingling / Burning in arms or legsSevere or Increasing HeadacheSeizure or ConvulsionsLoss of ConsciousnessDeteriorating ConsciousnessVomitingIncreasing Restlessness or Combativeness

    Observable Signs Flags (Any yes answer - Immediate call for Ambulance)

    Lying Motionless on Playing SurfaceBalance / Gait difficulties, Stumbling, laboured movementsDisorientation or confusion, inability to respond appropriatelyBlank or Vacant lookFacial injury or head trauma

    Memory Assessment

    Clascow Coma Scale (Any response less than 15 - Call For Ambulance)

    Eye Opening Response Spontaneously 4
    To speech 3
    To pain 2
    No response 1
    Best Verbal Response Oriented to time, place, and person 5
    Confused 4
    Inappropriate words 3
    Incomprehensible sounds 2
    No response 1
    Best Motor Response Obeys commands 6
    Moves to localized pain 5
    Flexion withdrawal from pain 4
    Abnormal flexion (decorticate) 3
    Abnormal extension (decerebrate) 2
    No response 1
    Total Score: Best response
    Comatose client 8 or less
    Totally unresponsive 3
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