Canada Soccer Concussion Assessment Medical Report

Canada Soccer Concussion Assessment Medical Report

This form serves as an aid to medical professionals to inform an athlete’s team staff regarding the diagnosis and status of concussion following an impact during a soccer activity. This form must be completed by a qualified medical doctor or nurse practitioner.

STEP 1: Consent to Disclose Personal Health Information

MUST be completed by athlete/parent/guardian prior to physician assessment

Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)

I, , authorize to disclose:

my personal health information, or

the personal health information of

to

consisting of the information provided regarding the injury, as requested below.

I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.

My Name: Address:

Telephone (Home or Mobile):

Witness Name:

STEP 2: Physician Assessment (Check one)

This patient has NOT been diagnosed with a concussion and can resume full participation in school, work, and sport activities without restriction.

This patient has been diagnosed with a concussion.

They have been advised about concussion management and may participate in training sessions once they have NO concussion symptoms AND have subsequently managed light exercise for 15 minutes WITHOUT concussion symptoms

A second report is necessary prior to returning to full contact soccer activities or games

This patient has recovered from a concussion and may participate in full contact training sessions and subsequently game play, if they remain clear of concussion symptoms.

If symptoms recur after return to soccer, a repeat medical assessment is necessary

Print Name: Date:

Modified from the Canadian Guidelines on Concussion in Sport

Return-to-School Strategy

The following is an outline of the Return-to-School Strategy that should be used to help student-athletes, parents, and teachers to partner in allowing the athlete to make a gradual return to school activities. Depending on the severity and type of the symptoms present, student-athletes will progress through the following stages at different rates. If the student-athlete experiences new symptoms or worsening symptoms at any stage, they should go back to the previous stage.

Soccer-Specific Return-to-Sport Strategy

The following is an outline of the Return-to-Sport Strategy that should be used to help athletes, coaches, trainers, and medical professionals to partner in allowing the athlete to make a gradual return to sport activities.

An initial period of 24-48 hours of rest is recommended before starting their Soccer-Specific Return-to-Sport Strategy. If the athlete experiences new symptoms or worsening symptoms at any stage, they should go back to the previous stage. It is important that youth and adult student-athletes return to full-time school activities before progressing to stage 5 and 6 of the Soccer-Specific Return-to-Sport Strategy. All athletes must provide their coach with a second Concussion Assessment Medical Report prior to returning to full contact sport activities.

How long will it take for concussion recovery?

Most athletes who sustain a concussion will make a complete recovery within 1-2 weeks while most youth athletes will recover within 1-4 weeks. Approximately 15-30% of patients will experience persistent symptoms (>2 weeks for adults; >4 weeks for youth) that may require additional medical assessment and management.

1 Parachute. (2017). Canadian Guideline on Concussion in Sport. Toronto: Parachute.