| Current injury | |||
| Date of injury | Description: mechanism, symptoms, management at time and after | ||
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| Removal from play: | Immediate | Delayed by _____ minutes | |
| Walked off | Assisted off | Stretchered off | |
| or Continued to play for _____ (minutes) | |||
| History of head injuries | |||
| Year or date occurred | Description (include: mechanism, LOC, PTA, RGA, other major symptoms/findings) | Management, including time lost from work or sport | Ongoing effects |
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