CONCUSSION MEDICAL CLEARANCE

MEDICAL CLEARANCE

Concussion is an important diagnosis and it is critical for doctors and athletes to understand the requirements for safe return to play (RTP). Naturally, this should only occur when the athlete is free of symptoms and after return to normal activity, school or work.

This Medical Clearance Form is used to record that you as a helthcare professional understand concussion, have seen and assessed a person as suitable to return to sports, either immediately or via a recognised RTP (Return to Play) program.
Today's Date:*

MonthDayYear
Date
Initial Concussion Date:*

MonthDayYear
Date
Days since injury
Patient's FIRST Name*
Patients LAST Name*
Patients date of birth*

MonthDayYear
Date
Activity when injured
Type in activity or sport
Mandatory rest period
For this sport, player age and level
Mandatory rest period elapsed?
For this sport
World Rugby Return to Play Protocol
For return to full contact play/training, all aspects of the concussion treatment program must have been completed:

Select as appropriate:*

	Yes	No	Unsure	N/A
No symptoms at rest
No symptoms with exercise
Not taking medication for concussion
Stepwise Return to Play completed (min. 5 days)
Has returned to work/school/normal activity
Post-injury test/s equivalent to baseline (or within normal range)