2019 Mayo Clinic Preseason Concussion Assessment

BACKGROUND

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* 1. Today's Date:

Date / Time

Date

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* 2. Email address

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* 3. Athlete information

First name

Middle initial

Last name

Date of birth

Best contact number

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* 4. What is your address?

Street

Other

City

Zip Code

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* 5. Guardian of Athlete Information

First

Middle initial

Last

Best contact number

Not Applicable (type "NA")

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* 6. What is the athlete's age?

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* 7. What is the sex of the athlete?

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* 8. What is the athlete's current (primary) sport?

Hockey

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* 9. Sports Organization Information (primary)

Sports Organization Name

Team Name

Primary Position Played (for this team)

Additional Positions Played (if applicable, for this team)

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* 10. What is the athlete's secondary sport (if applicable)

Football(Tackle)

Football(Flag)

Lacrosse

Soccer(Heading allowed)

Soccer(Non-Heading)

Baseball

Softball

Cheerleading

Basketball

Other (please specify)

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* 11. Sports Organization Information (secondary)

Sports Organization Name

Team Name

Primary Position Played (for this team)

Additional Positions Played (if applicable, for this team)

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* 12. What grade is the athlete currently in at school?

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* 13. What is the athlete's dominant hand?

Right

Left

Mixed

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* 14. How many concussions has the athlete had in the past?

	None	1	2	3	4	5	More than 5
Number of concussions	Number of concussions None	Number of concussions 1	Number of concussions 2	Number of concussions 3	Number of concussions 4	Number of concussions 5	Number of concussions More than 5

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* 15. What was the most recent concussion?

	Never	Within 1 month	Within 3 months	Within 6 months	Within the last year	Within the last 2 years	More than 2 years ago
The most recent concussion was...	The most recent concussion was... Never	The most recent concussion was... Within 1 month	The most recent concussion was... Within 3 months	The most recent concussion was... Within 6 months	The most recent concussion was... Within the last year	The most recent concussion was... Within the last 2 years	The most recent concussion was... More than 2 years ago

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* 16. How old was the athlete when he/she had his/her first concussion? (Age in years)

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* 17. Has the athlete ever experienced more than one concussion in 10 days time?

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* 18. How long was the recovery after the most recent concussion?

	Not Applicable	1 - 3 days	1 week	2 weeks	3 - 4 weeks	5 - 8 weeks	More than 8 weeks
The duration of the recovery was...	The duration of the recovery was... Not Applicable	The duration of the recovery was... 1 - 3 days	The duration of the recovery was... 1 week	The duration of the recovery was... 2 weeks	The duration of the recovery was... 3 - 4 weeks	The duration of the recovery was... 5 - 8 weeks	The duration of the recovery was... More than 8 weeks

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* 19. How many times has the athlete taken a hit to the head or body and experienced any of the following:

nausea, vomiting, headache, vision disturbance, dizziness, balance problems, light or noise sensitivity, disorientation, confusion, loss of memory for the event, or sudden change in mood or behavior?

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* 20. When was the last time the athlete experienced this?

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* 21. Does the athlete have any of the following:

Depression

Anxiety

Post-traumatic stress disorder (PTSD)

Attention deficit hyperactivity disorder (ADHD/ADD)

Autism Spectrum Disorder

Other (please specify)

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* 22. Please answer the following...

	No	Yes
Has the athlete ever been hospitalized or had medical imaging done (CT or MRI) for a head injury?	Has the athlete ever been hospitalized or had medical imaging done (CT or MRI) for a head injury? No	Has the athlete ever been hospitalized or had medical imaging done (CT or MRI) for a head injury? Yes
Has the athlete ever been diagnosed with headaches or migraines?	Has the athlete ever been diagnosed with headaches or migraines? No	Has the athlete ever been diagnosed with headaches or migraines? Yes
Does the athlete have ADD/ADHD?	Does the athlete have ADD/ADHD? No	Does the athlete have ADD/ADHD? Yes
Does the athlete have a seizure disorder?	Does the athlete have a seizure disorder? No	Does the athlete have a seizure disorder? Yes
Has the athlete ever been diagnosed with depression, anxiety, or other psychiatric disorder?	Has the athlete ever been diagnosed with depression, anxiety, or other psychiatric disorder? No	Has the athlete ever been diagnosed with depression, anxiety, or other psychiatric disorder? Yes
Has anyone in the family ever been diagnosed with any of these problems?	Has anyone in the family ever been diagnosed with any of these problems? No	Has anyone in the family ever been diagnosed with any of these problems? Yes

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* 23. Please answer the following...

	No	Yes
Does the athlete have a learning disability or dyslexia?	Does the athlete have a learning disability or dyslexia? No	Does the athlete have a learning disability or dyslexia? Yes
If yes, please specify:
Is the athlete on any medications?	Is the athlete on any medications? No	Is the athlete on any medications? Yes
If yes, please specify:

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20% of survey complete.