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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.