Demographic Information:
a) Please indicate the level of Bantam Hockey your child participates in:
1 A		□
2 AA		□
3 AAA		□
b) Please indicate your child’s current age:
1 12 years		□
2 13 years		□
3 14 years		□
c) Have you/do you participate in high level (ex. Pro or semi pro), medium level (ex. Competitive leagues), or low level (ex. Recreational) sports:
1 High level			□
2 Medium level			□
3 Low/Rec. level			□
4 No sport participation			□
d) What is your status of guardianship to the participating child?
1 Mother			□
2 Father			□
3 Male Legal Guardian			□
4 Female Legal Guardian			□
Questionnaire:
1) Does a loss of consciousness determine whether a concussion has occurred? (Please check one)
□ Yes 1		□ No 2
2) Can a player who has suffered a concussion return to play in the same day? (Please check one)
□ Yes 1		□ No 2
3) A concussion may be caused by a blow to the neck, jaw, or elsewhere in the body? (Please check one)
□ Yes 1		□ No 2
4) Is it necessary for a player to be medically evaluated after having their bell rung? (Please check one)
□ Yes 1		□ No 2
5) The following are signs and symptoms of concussion.  (Please circle True or False)
T	F	Headache
T	F	Neck pain
T	F	Difficulty with urination
T	F	Dizziness
T	F	Lowered pulse rate
T	F	Ringing in the ears
T	F	Feeling dazed or in a “fog”
T	F	Difficulty with defecation
T	F	Difficulty falling asleep
T	F	Slurred speech
T	F	Difficulty concentrating
T	F	Drowsiness/fatigue
T	F	Hearing voices
T	F	Sinus congestion
T	F	Inability to describe time and place
T	F	Seizures
T	F	Feelings of euphoria
T	F	Inability to swallow
T	F	Chest pain
T	F	Feeling of “pressure” in the head
T	F	Difficulty with memory
T	F	Feeling nauseous
T	F	Problems with vision
T	F	Increased emotion/irritability
T	F	Increased sleeping
6) Has your child ever suffered a concussion? (Please check one)
□ Yes 1		□ No 2