Screening

Concussion SCAT Assessment Form

3 pages20 fieldsHIPAA-ready

Form preview

formisoft.com/f/concussion-scat-screening
Patient Name
Date of Injury
Mechanism of Injury
Loss of Consciousness
Amnesia Duration
Select...
Symptom Severity Checklist
Headache Severity (0-6)
Dizziness Severity (0-6)
Orientation Score
Immediate Memory Recall
Concentration Score
Balance Test (BESS) Score
Coordination Test
Select...
Delayed Recall Score
Red Flag Symptoms
Return-to-Play Status
Select...
Submit

The Concussion SCAT Assessment Form is based on the Sport Concussion Assessment Tool, the internationally recognized standard for evaluating athletes and individuals suspected of sustaining a concussion. This comprehensive form guides clinicians through a systematic multi-component evaluation including observable signs, symptom checklist, cognitive screening with orientation and memory testing, neurological screening, and balance examination using the modified Balance Error Scoring System (BESS).

The symptom evaluation section includes a 22-item graded symptom checklist where patients rate each symptom on a severity scale from 0 to 6, providing both a total symptom count and a cumulative severity score. The cognitive assessment covers orientation questions, immediate and delayed word recall, and concentration tasks. The neurological screen documents cervical spine assessment, coordination testing, and gait evaluation, creating a thorough clinical record of the patient's post-injury status.

Essential for sports medicine physicians, athletic trainers, emergency departments, urgent care centers, and concussion specialty clinics, this form supports evidence-based return-to-play and return-to-learn decision-making. It can be used for initial sideline assessment, serial monitoring during recovery, and comparison with baseline testing to guide safe and appropriate clearance for activity.

What's included

  • 22-item graded symptom severity checklist
  • Cognitive screening with orientation and memory tasks
  • Modified BESS balance examination scoring
  • Neurological screen including coordination and gait
  • Red flag symptom identification and documentation
  • Return-to-activity decision support and status tracking

Who uses this template

  • Sideline concussion evaluation during sporting events
  • Emergency department head injury assessment and documentation
  • Serial concussion monitoring during recovery and rehabilitation
  • Return-to-play and return-to-learn clearance evaluation

All form fields

16 fields across 3 pages. Customize any field after signing up.

Patient NameText
Date of InjuryDate
Mechanism of InjuryLong Text
Loss of ConsciousnessMultiple Choice
Amnesia DurationDropdown
Symptom Severity ChecklistCheckbox
Headache Severity (0-6)Multiple Choice
Dizziness Severity (0-6)Multiple Choice
Orientation ScoreNumber
Immediate Memory RecallNumber
Concentration ScoreNumber
Balance Test (BESS) ScoreNumber
Coordination TestDropdown
Delayed Recall ScoreNumber
Red Flag SymptomsCheckbox
Return-to-Play StatusDropdown

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