PARENT/GUARDIAN LETTER (SAMPLE)
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Name
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Completed by
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Parent notified via:
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Phone _____ In-person ______ Other (please specify)
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Your son/daughter was suspected of having a concussion on:
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Description of injury event
Initial symptoms observed
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Dazed or “glassy eyes”
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Confused or disoriented
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Vomiting
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Loss of balance or clumsiness
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Difficulty following directions
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Seizures
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Loss of consciousness
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More emotional
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Other: _______________________________________________________________________________________
Symptoms Reported
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Headache
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Dizziness
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Nausea
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Low energy
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Difficulty remembering
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Difficulty concentrating
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Visual problem
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Sensitivity to light
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Sensitivity to noise
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Other: _______________________________________________________________________________________
If you notice the following, call 911 or take your child to the ER:
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Difficulty Breathing
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Decreased level of consciousness
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Increase intensity of headaches
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Unequal, dilated, unreactive pupils
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Mental status changes
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Seizures
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Neck Pain
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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.
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