PARENT/GUARDIAN LETTER (SAMPLE)
Name
Completed by
Parent notified via:
Phone _____ In-person ______ Other (please specify)
Your son/daughter was suspected of having a concussion on:
Description of injury event
Initial symptoms observed
Dazed or “glassy eyes”
Confused or disoriented
Vomiting
Loss of balance or clumsiness
Difficulty following directions
Seizures
Loss of consciousness
More emotional
Other: _______________________________________________________________________________________
Symptoms Reported
Headache
Dizziness
Nausea
Low energy
Difficulty remembering
Difficulty concentrating
Visual problem
Sensitivity to light
Sensitivity to noise
Other: _______________________________________________________________________________________
If you notice the following, call 911 or take your child to the ER:
Difficulty Breathing
Decreased level of consciousness
Increase intensity of headaches
Unequal, dilated, unreactive pupils
Mental status changes
Seizures
Neck Pain
Parent Information Checklist:
Take your child to your physician for follow up care.
During the first 24-72 hours, limit cognitive stimulation such as texting, video games, computer use, reading, and writing.
No practice, games, or physical activity until advised or cleared by a physician.
Call the school’s front office, counselor, or student services coordinator to let the school know that your child has a concussion.
8 to 10 hours of continuous sleep at night is recommended. Avoid frequent napping.
Must have a medical clearance from a licensed health care provider before your child may return to practice or play.
