Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Concussion SCAT Assessment Form
Your information
Patient Name *
Date of Injury
____ / ____ / ________
Mechanism of Injury
Loss of Consciousness
Amnesia Duration
Symptom Severity Checklist
Headache Severity (0-6)
Dizziness Severity (0-6)
Additional details
Immediate Memory Recall
Coordination Test
Red Flag Symptoms
Concussion SCAT Assessment Form template from formisoft.com. formisoft.com/intake-templates/concussion-scat-screening