Office-Based Concussion Evaluation - Sanford Health - sanfordhealth 2026

1. Click ‘Get Form’ to open the Office-Based Concussion Evaluation in the editor.
2. Begin by entering the patient's name, date of birth, age, level of education, and school in the designated fields. This information is crucial for identifying the patient.
3. Fill in the date of evaluation and date of injury. Indicate who is reporting the information by selecting from options such as Patient, Parent, or Spouse.
4. Specify the cause of injury by checking appropriate boxes (e.g., MVA, Fall) and provide details about the mechanism of injury and location of contact.
5. Document any loss of consciousness or amnesia by marking 'Yes' or 'No' and providing duration if applicable. This section helps assess the severity of the concussion.
6. Rate symptoms using a scale from 0 to 6 for various categories like Physical, Cognitive, Sleep, and Emotional. Ensure to complete both Initial and Current ratings.
7. Complete risk factors for protracted recovery by checking all that apply. This will assist healthcare providers in understanding potential complications.
8. Finally, review all entries for accuracy before saving or sharing your completed form through our platform.

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