Name:____________________________	Date:_________
Sport/Team:_____________________	Mouth Guard?	Y	N
1) SIGNS
Was there loss of consciousness or unresponsiveness?		Y	N
Was there seizure or convulsive activity?		Y	N
Was there a balance problem/unsteadiness?		Y	N
2) MEMORY
Modified Maddocks questions (check those correct)
At what venue are we? _____	Which half is it? ____	Who scored last? ____	What team did we play last? ____
Did we win last game? ____
3) SYMPTOM SCORE
Total number of positive symptoms (from “ SYMPTOMS” box on other side of the card) =________
4) COGNITIVE ASSESSMENT(Check those correct)
5 word recall (Examples)		Immediate	Delayed (after concentration tasks)
Word 1_______	cat	____	____
Word 2_______	pen	____	____
Word 3_______	shoe	____	____
Word 4_______	book	____	____
Word 5_______	car	____	____
Months in reverse order (circle those incorrect) Jun-May-Apr-Mar-Feb-Jan-Dec-Nov-Oct-Sep-Aug-Jul
OR
Digits backwards (check those correct)
5–2–8	3–9–1	____
6–2–9–4	4–3–7–1	____
8–3–2–7–9	1–4–9–3–6	____
7–3–9–1–4–2	5–1–8–4–6–8	____
Ask delayed 5-word recall now
5) NEUROLOGICAL SCREENING
	Pass	Fail
Speech	____	____
Eye Motion and Pupils	____	____
Pronator Drift	____	____
Gait Assessment	____	____
Any neurologic screening abnormality necessitates formal neurologic or hospital assessment.