Concussion home instructions________________________________________________________________________________________

I believe that __________________________ sustained a concussion on ________________________. To make sure he/she recovers, please follow the following important recommendations:

1. Please remind________________________________ to report to the athletic training room tomorrow at ____________________ for a follow‐up evaluation.

2. Please review the items outlined on the enclosed Physician Referral Checklist. If any of these problems develop prior to his/her visit, please call_____________________at ___________________ or contact the local EMS. Otherwise, you can follow the instructions outlined below.

It is OK to	There is NO need to	Do NOT
• Use acetaminophen (Tylenol for headaches)	• Stay in bed	• Drink alcohol
• Eat a light diet	• Check eyes with flashlight	• Eat or drink, spicy foods or drinks
• Use ice pack on head neck as needed for comfort	• Wake up every hour
• Return to school	• Test reflexes
• Go to sleep
• Rest no strenuous activity or sports

Special recommendations: __________________________________________________________________________________________________________________________________________________________________________

Recommendations provided to: __________________________________________________________

Recommendations provided by: ________________Date: ________________ Time: ________________

Please feel free to contact me if you have any questions. I can be reached at: ___________________

Signature: ___________________________________ Date: ___________________________________