Athlete Background

Record patient information and medical history

Patient Name

Date of Birth

Sport / Team

Date/Time of Injury

Age

Gender

Dominant Hand

Years of Education Completed

Previous Diagnosed Concussions

Assessment Type

Medical History

Hospitalized for head injury?

Diagnosed/treated for headache disorder or migraines?

Diagnosed with learning disability / dyslexia?

Diagnosed with ADD / ADHD?

Diagnosed with depression, anxiety, or other psychiatric disorder?

Current Medications

2

Symptom Evaluation

Rate each symptom from 0 (none) to 6 (severe)

Score: 0/22

Symptom	0	1	2	3	4	5	6

Do symptoms get worse with physical activity?

Do symptoms get worse with mental activity?

If 100% is feeling perfectly normal, what percent of normal do you feel?

%

3

Cognitive Screening (SAC)

Standardized Assessment of Concussion

Score: 0/30

Orientation Score: 0/5

Ask the patient: "What month is it?", "What is the date today?", etc.

What month is it?

What is the date today?

What day of the week is it?

What year is it?

What time is it right now? (within 1 hour)

Immediate Memory Score: 0/15

"I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order."

Select Word List

Trial 10/5

Trial 20/5

Trial 30/5

Concentration Score: 0/5

Digits Backward (4 points)

"I am going to read a string of numbers and when I am done, you repeat them back to me in reverse order. For example, if I say 7-1-9, you would say 9-1-7."

4-9-3 → 3-9-4

3-8-1-4 → 4-1-8-3

6-2-9-7-1 → 1-7-9-2-6

7-1-8-4-6-2 → 2-6-4-8-1-7

Months in Reverse Order (1 point)

"Now tell me the months of the year in reverse order. Start with the last month and go backward. So you'll say December, November... Go ahead."

Dec - Nov - Oct - Sept - Aug - Jul - Jun - May - Apr - Mar - Feb - Jan

4

Neurological Screen

Assess neurological function

Can the patient read aloud and follow instructions without difficulty?

Does the patient have a full range of pain-free PASSIVE cervical spine movement?

Without moving their head or neck, can the patient look side-to-side and up-and-down without double vision?

Can the patient perform the finger-nose coordination test normally?

Can the patient perform tandem gait normally?

5

Balance Examination (mBESS)

Modified Balance Error Scoring System — Count errors for each stance

Errors: 0/30

Which foot was tested? (non-dominant foot)

Testing Surface

Error Criteria: Hands lifted off iliac crest, opening eyes, step/stumble/fall, moving hip into more than 30° abduction, lifting forefoot or heel, remaining out of test position for more than 5 seconds. Each error counts once per stance (maximum 10 errors per stance).

Double Leg Stance

Feet together, hands on hips, eyes closed — 20 seconds

0

Single Leg Stance (Non-Dominant Foot)

Standing on non-dominant foot, hands on hips, eyes closed — 20 seconds

0

Tandem Stance (Non-Dominant Foot at Back)

Heel-to-toe with non-dominant foot behind, hands on hips, eyes closed — 20 seconds

0

6

Delayed Recall

Perform after 5 minutes have elapsed since Immediate Memory

Score: 0/5

"Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order."

Selected Word List: A

7

Scoring Summary & Decision

Review all assessment scores

SCAT5 Scoring Summary

Patient: — | Date: —

Symptom Number

0

of 22

Symptom Severity

0

of 132

Orientation

0

of 5

Immediate Memory

0

of 15

Concentration

0

of 5

SAC Total

0

of 30

Balance Errors

0

of 30

Delayed Recall

0

of 5

⚠️ Clinical Decision Required

Scoring on the SCAT5 should NOT be used as a stand-alone method to diagnose concussion, measure recovery, or make decisions about an athlete's readiness to return to competition.

The diagnosis of a concussion is a clinical judgment, ideally made by a physician or other licensed medical professional. An athlete may have a concussion even if their SCAT5 is "normal."

If the athlete is known to you prior to their injury, are they different from their usual self?

Concussion Diagnosed?

Clinical Notes