Concussions are a type of brain injury that affects the way the brain normally works. It can be caused by a bump, blow or jolt to the head or a fall or blow to the body that causes the head and brain to move quickly back and forth.
Laconia School District: Return to School Physician Form
SCHOOL RECOMMENDATIONS – Laconia School District
Student Name: ___________________________________________ Date of Evaluation: ____________________
The above named student has reported that they have been diagnosed with a concussion and is currently under your care. Please take a moment to complete this form of recommendations so that we may better care for this student at school and avoid increasing concussion symptoms and delaying recovery.
Please allow the following academic recommendations from ___________ through_____________. (Please see reverse side for additional information) ------------------------------------------------------------------------------------------------>
Attendance
No school until symptoms free/significant decrease in symptoms
No school for school day(s)
Part time attendance for school day(s) as tolerated
Full school days as tolerated
Visual Stimulus
Allow student to wear sunglasses in school
Preprinted notes for class material or note taker
No smart boards, projectors, computers, TV screens or other bright screen
Enlarged font when possible
Audible Stimulus
Allow student to leave class 5 minutes early to avoid noisy hallway
Audible learning (discussions, reading out loud, if possible text to speech programs or Kindle)
Avoidance of loud and crowded places (auditoriums, lunchrooms, recess, music/band/choir)
Workload/Multi-Tasking
No homework
Limit homework to ________ minutes a night
Adjust workload when possible
Reduce overall amount of makeup work, class work and homework when possible
Testing
No testing
No testing until caught up on school work
Extra time to complete tests
No more than one test a day/every other day
Oral testing
Open book or take home testing when possible
Testing in a quiet place
Physical Exertion
No physical exertion/sports/gym/recess
Aerobic, noncontact, nongroup activities as tolerated
No contact sports or activities
Cleared for all physical exertion. Begin return to play protocol (see back side).
Additional Recommendations
Other: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Symptom List (the patient is complaining of today)
□ Headache □ Difficulty concentrating □ Sensitivity to light □ Trouble falling asleep
□ Visual problems □ Difficulty remembering □ Sensitivity to noise □ Drowsiness
□ Dizziness □ Feeling slowed down □ Feeling more emotional □ Sleeping less than usual
□ Nausea □ Feeling mentally foggy □ Irritability □ Sleeping more than usual
□ Fatigue □ Balance Problems
The student has been scheduled for a follow-up medical appointment/revision of recommendations on ________
Provider’s Signature: ____________________________________ Provider’s Name: __________________________
Head Injury Warning Sheet
This is a medical follow-up sheet for your health and safety. Often the signs and symptoms of head injuries do not appear immediately after a trauma but hours after the injury itself. The purpose of this fact sheet is to alert you to signs and symptoms of significant head injuries.
The appearance OR WORSENING of any of these symptoms tells you that you may have sustained a significant head injury that requires medical attention. If any of these symptoms appear OR WORSEN, contact your family physician or report to your local Emergency Room. Very sick people should be transported to the emergency room by ambulance; do not hesitate to call for an ambulance if you think one may be necessary.
If you develop one or more of the following symptoms following a head injury or if existing symptoms get worse, medical help should be sought.
· Loss of consciousness
· Convulsions
· Severe headache
· Dizziness, poor balance, or unsteadiness
· Unequal pupils
· Bleeding or clear fluid from ears/nose
· Nausea or vomiting
· Weakness in either arm or leg
· Abnormal drowsiness or sleepiness
· Difficulty remembering recent events/facts
· Loss of appetite · Mental confusion or strangeness
· Persistent ringing in the ears
Slurring of the speech
· Stiffening of the neck
Head injuries can present signs and symptoms that seem funny and are taken too lightly. You should rest and generally take it easy until you are feeling well.
Medications/Cold Packs:
Refrain from taking aspirin, ibuprofen, and other medications unless ordered by medical personnel. Acetaminophen (Tylenol) may be taken for existing symptoms; seek medical attention if symptoms are getting worse. Use ice packs for the head and neck as needed for comfort.
Sleep/Rest & Rest:
You can go to sleep. Rest is very important to allow the brain to recover. Eat a light diet.
Return to School:
Return to school when you feel up to it. BEFORE RETURNING TO CLASSES, REPORT TO THE NURSE’S OFFICE.
Activities:
In general, you should avoid any and all activities (mental or physical) that make you feel worse. Avoid recreational and sports activities until your athletic trainer or doctor has okayed them; REPORT TO ATHLETIC TRAINER BEFORE RESUMING SPORT.
This is a medical follow-up sheet for your health and safety. Often the signs and symptoms of head injuries do not appear immediately after a trauma but hours after the injury itself. The purpose of this fact sheet is to alert you to signs and symptoms of significant head injuries.
The appearance OR WORSENING of any of these symptoms tells you that you may have sustained a significant head injury that requires medical attention. If any of these symptoms appear OR WORSEN, contact your family physician or report to your local Emergency Room. Very sick people should be transported to the emergency room by ambulance; do not hesitate to call for an ambulance if you think one may be necessary.
If you develop one or more of the following symptoms following a head injury or if existing symptoms get worse, medical help should be sought.
· Loss of consciousness
· Convulsions
· Severe headache
· Dizziness, poor balance, or unsteadiness
· Unequal pupils
· Bleeding or clear fluid from ears/nose
· Nausea or vomiting
· Weakness in either arm or leg
· Abnormal drowsiness or sleepiness
· Difficulty remembering recent events/facts
· Loss of appetite · Mental confusion or strangeness
· Persistent ringing in the ears
Slurring of the speech
· Stiffening of the neck
Head injuries can present signs and symptoms that seem funny and are taken too lightly. You should rest and generally take it easy until you are feeling well.
Medications/Cold Packs:
Refrain from taking aspirin, ibuprofen, and other medications unless ordered by medical personnel. Acetaminophen (Tylenol) may be taken for existing symptoms; seek medical attention if symptoms are getting worse. Use ice packs for the head and neck as needed for comfort.
Sleep/Rest & Rest:
You can go to sleep. Rest is very important to allow the brain to recover. Eat a light diet.
Return to School:
Return to school when you feel up to it. BEFORE RETURNING TO CLASSES, REPORT TO THE NURSE’S OFFICE.
Activities:
In general, you should avoid any and all activities (mental or physical) that make you feel worse. Avoid recreational and sports activities until your athletic trainer or doctor has okayed them; REPORT TO ATHLETIC TRAINER BEFORE RESUMING SPORT.