Meliora Medical

Return2Play Head Injury Report Form

Please complete the form below to record the injury details.

Location School/Club (the client who has contracted our services - injury report will be sent to our contact here) * Location School/Club (the client who has contracted our services - injury report will be sent to our contact here)

Form completed by: * Form completed by:

Coach/contact email (if opposition player - a copy of the report will be sent here)

Second Coach/contact email (if needed)

School/Club name (if opposition player)

Player's Name *

Player Date of Birth *

Age Group *

Date of Injury *

Estimated time of injury *

Diagnosis

Concussion

Head injury (possible concussion)

Head injury (concussion unlikely)

History *

Examination Findings *

Comment/Advice *

Outcome *

Discharged with coach/parent/guardian

Referred for further medical care/investigation (non-urgent)

Referred to hospital (ASAP)

Emergency transfer to hospital (999 Ambulance)

OtherOther

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Return2Play Head Injury Report Form

Return2Play Head Injury Report Form

Services

School Services

In Clinic Services

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Return2Play Head Injury Report Form

Return2Play Head Injury Report Form

School Services

In Clinic Services