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Sport Concussion Assessment Tool (SCAT5)
First Name*
M.I.
Last Name*
Preferred Name
Pronouns Used
Student/Staff/Faculty ID#*
Date of Birth*
Today's Date*
Sex at Birth (Please check box below)*
Male
Female
Intersex
Legal Sex Designation (if different from Sex at Birth)*
Male
Female
X
Gender Identity (Please check box below)
Man
Transgender Man/ Woman-to-Man
Genderqueer/Non-Binary(Neither exclusively male or female)
Woman
Transgender Woman/Man-to-Woman
Identity Not Listed
Athlete Background
Sport / Team / School
Date / Time of Injury*
Years of Education Completed
Age
Dominant Hand
How many diagnosed concussions has the athlete had in the past?
When was the most recent concussion?
How long was the recovery (time to being cleared to play) from the most recent concussion?
Hospitalized for a head injury?
YES
NO
Have you ever been diagnosed / treated for headache disorder or migraines?
YES
NO
Have you ever been diagnosed with a learning disability / dyslexia?
YES
NO
Have you ever been diagnosed with ADD / ADHD?
YES
NO
Have you ever been diagnosed with depression, anxiety or other psychiatric disorder?
YES
NO
Please list all current medications:
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SYMPTOM EVALUATION
The athlete should be given the symptom form and asked to read this instruction paragraph out loud then complete the symptom scale. For the baseline assessment, the athlete should rate his/her symptoms based on how he/she typically feels,and for the post-injury assessment, the athlete should rate their symptoms at this point in time.
BASELINE
POST-INJURY
(0 - None) (1-2 MILD) (3-4 MODERATE) (5-6 SEVERE)
0
1
2
3
4
5
6
1. Headache
0
1
2
3
4
5
6
0
1
2
3
4
5
6
2. “Pressure in head”
0
1
2
3
4
5
6
0
1
2
3
4
5
6
3. Neck Pain
0
1
2
3
4
5
6
0
1
2
3
4
5
6
4. Nausea or vomiting
0
1
2
3
4
5
6
0
1
2
3
4
5
6
5. Dizziness
0
1
2
3
4
5
6
0
1
2
3
4
5
6
6. Blurred vision
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7. Balance Problems
0
1
2
3
4
5
6
0
1
2
3
4
5
6
8. Sensitivity to light
0
1
2
3
4
5
6
0
1
2
3
4
5
6
9. Sensitivity to noise
0
1
2
3
4
5
6
0
1
2
3
4
5
6
10. Feeling slowed down
0
1
2
3
4
5
6
0
1
2
3
4
5
6
11. Feeling like "in a fog"
0
1
2
3
4
5
6
0
1
2
3
4
5
6
12. "Don't feel right"
0
1
2
3
4
5
6
0
1
2
3
4
5
6
13. Difficulty concentrating
0
1
2
3
4
5
6
0
1
2
3
4
5
6
14. Difficulty remembering
0
1
2
3
4
5
6
0
1
2
3
4
5
6
15. Fatigue or low energy
0
1
2
3
4
5
6
0
1
2
3
4
5
6
16. Confusion
0
1
2
3
4
5
6
0
1
2
3
4
5
6
17. Drowsiness
0
1
2
3
4
5
6
0
1
2
3
4
5
6
18. More emotional
0
1
2
3
4
5
6
0
1
2
3
4
5
6
19. Irritability
0
1
2
3
4
5
6
0
1
2
3
4
5
6
20. Sadness
0
1
2
3
4
5
6
0
1
2
3
4
5
6
21. Nervous or Anxious
0
1
2
3
4
5
6
0
1
2
3
4
5
6
22. Trouble falling asleep (if applicable)
0
1
2
3
4
5
6
Total Number of Symptoms Out of 22
Symptom Severity Score Out of 132
Do your symptoms get worse with physical activity?
Yes
No
Do your symptoms get worse with mental activity?
Yes
No
If 100% is feeling perfectly normal, what percent of normal do you feel?
If not 100%, explain why below:
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