HIA (HEADSAFE INJURY ASSESSMENT)

RECOMMENDATION
DIAGNOSIS*
REFFERED TO:*
HEAD INJURY INFO GIVEN (PLAYER):*
TRANSPORT:*
HEAD INJURY INFO GIVEN (OTHERS):*
OTHER INJURY*
FOLLOW-UP:*
MINIMUM REST BEFORE 6 STEP RETURN TO PLAY (RTP) CAN BE COMMENCED (if asymptomatic and off medication)*
ADDITIONAL COMMENTS (Remember: WHEN IN DOUBT, SIT THEM OUT!!!!!)
Assessor LAST name
Assessor FIRST name
Assessor Qualification
Assessor E-mail
Assessor Phone Number

Area CodePhone Number
Signature

Clear
Should be Empty:

Rows	YES	No	Reported	Uncertain
Loss of consciousness or responsiveness
Lying motionless on ground
Slow to get up
Unsteady on feet
Balance problems or falling over
Incoordination
Grabbing/Clutching of head
Dazed, blank or vacant look
Confused
Not aware of plays or events

Rows	YES	No	Reported	Uncertain
Athlete complains of neck pain
Deteriorating conscious state
Increasing confusion or irritability
Severe or increasing headache
Repeated vomiting
Unusual behaviour change
Seizure or convulsion
Double vision
Weakness or tingling/burning in arms or legs

Rows	0	1
What venue are we at today?
Which half is it now?
Who scored last in this match?
What team did you play last week/game?
Did your team win the last game?

Rows	Normal	Abnormal	Equivocal	Not Assessed
Pupil reaction
Pupil tracking
Cranial Nerves
Neck movement (all directions)
Upper Limb power
Upper Limb sensation
Upper Limb reflexes
Lower Limb power
Lower Limb sensation
Lower Limb reflexes