Concussion Signs and Symptoms

Checklist

Student’s Name: _____________________________________________ Student’s Grade: _______ Date/Time of Injury: _______________

Where and How Injury Occurred: (Be sure to include cause and force of the hit or blow to the head.) ____________________________________________

_______________________________________________________________________________________________________________________

Description of Injury: (Be sure to include information about any loss of consciousness and for how long, memory loss, or seizures following the injury, or previous

concussions, if any. See the section on Danger Signs on the back of this form.) __________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

DIRECTIONS: 

Use this checklist to monitor

students who come to your office

with a head injury. Students should

be monitored for a minimum of 

30 minutes. Check for signs or

symptoms when the student first

arrives at your office, fifteen minutes

later, and at the end of 30 minutes. 

Students who experience one or

more of the signs or symptoms of

concussion after a bump, blow, or

jolt to the head should be referred

to a health care professional with

experience in evaluating for

concussion. For those instances

when a parent is coming to take the

student to a health care professional,

observe the student for any new or

worsening symptoms right before

the student leaves. Send a copy of

this checklist with the student for the

health care professional to review.

OBSERVED SIGNS 0

MINUTES

15

MINUTES

30

MINUTES MINUTES

Just prior to 

leaving

Appears dazed or stunned

Is confused about events

Repeats questions

Answers questions slowly

Can’t recall events prior to the hit, bump, or fall

Can’t recall events after the hit, bump, or fall

Loses consciousness (even briefly)

Shows behavior or personality changes

Forgets class schedule or assignments

PHYSICAL SYMPTOMS

Headache or “pressure” in head

Nausea or vomiting

Balance problems or dizziness

Fatigue or feeling tired

Blurry or double vision

Sensitivity to light

Sensitivity to noise

Numbness or tingling

Does not “feel right”

COGNITIVE SYMPTOMS

Difficulty thinking clearly

Difficulty concentrating

Difficulty remembering

Feeling more slowed down

Feeling sluggish, hazy, foggy, or groggy

EMOTIONAL SYMPTOMS

Irritable

Sad

More emotional than usual

Nervous

To download this checklist in Spanish, 

please visit: www.cdc.gov/Concussion.

Para obtener una copia electrónica de 

esta lista de síntomas en español, 

por favor visite: www.cdc.gov/Concussion. 

0102 yaM

More
Danger Signs: 

Be alert for symptoms that worsen over time. The

student should be seen in an emergency department

right away if s/he has: 

r One pupil (the black part in the middle of the eye)

larger than the other 

r Drowsiness or cannot be awakened 

r A headache that gets worse and does not go away 

r Weakness, numbness, or decreased coordination 

r Repeated vomiting or nausea 

r Slurred speech 

r Convulsions or seizures 

r Difficulty recognizing people or places 

r Increasing confusion, restlessness, or agitation 

r Unusual behavior 

r Loss of consciousness (even a brief loss of

consciousness should be taken seriously)

Additional Information About This Checklist: 

This checklist is also useful if a student appears to have

sustained a head injury outside of school or on a previous

school day. In such cases, be sure to ask the student

about possible sleep symptoms. Drowsiness, sleeping

more or less than usual, or difficulty falling asleep may

indicate a concussion.

To maintain confidentiality and ensure privacy, this

checklist is intended only for use by appropriate school

professionals, health care professionals, and the

student’s parent(s) or guardian(s). 

For a free tear-off pad with additional copies of this 

form, or for more information on concussion, visit:

www.cdc.gov/Concussion.

Resolution of Injury: 

__ Student returned to class

__ Student sent home

__ Student referred to health care professional with experience in evaluating for concussion

SIGNATURE OF SCHOOL PROFESSIONAL COMPLETING THIS FORM: _________________________________________

TITLE: ____________________________________________________________________________

COMMENTS:

For more information on concussion and to order additional

materials for school professionals FREE-OF-CHARGE, visit: www.cdc.gov/Concussion.

U.S. Department of HealtH anD HUman ServiceS

centerS for DiSeaSe control anD prevention