About this questionnaire

In order to better assist you and other athletes, OneHitAway needs an assessment of your current condition. We will check back with you in the future to evaluate your progress and determine where additional help might be needed.  We want to track your success.  Please fill out the questions to the best of your ability, there are no wrong answers.  We are part of your team!

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* 1. Recipient Name

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* 2. Date of Injury

Date / Time

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* 3. Are you filling this out for someone?

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* 4. If "yes", name and relationship:

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* 5. Your email address:

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* 6. Best phone number to reach you:

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* 7. Alternate contact:

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* 8. Address:

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* 9. Is this your first concussion?

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* 10. If "no" how many other concussions have you experienced (that you know of):

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* 11. Please describe the event that resulted in your most recent concussion, including the location of impact:

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* 12. Was your most recent concussion sports related?

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* 13. If "yes", which sport?

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