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)

BEHAVIOR	RESPONSE	SCORE
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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