SFC Concussion Questionnaire - Sturt Football Club

Date of form submission *

Squad *

Under 14
Under 16
Under 18

PLAYER DETAILS

Player Name *

First

Last

Player Date of Birth *

Player Email *

Player Mobile Number *

Player Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Have you ever experienced a Concussion/Traumatic Brain Injury (TBI)? *

Yes
No

If YES, when? Dates (Month/Year) Please detail all

Have you ever received medical attention for a head injury? *

Yes
No

If YES, when? Dates (Month/Year)

Were you referred to a Doctor?

Yes
No

Did you undergo a SCAT (Sport Concussion Assessment Tool) test administered by a Doctor?

Yes
No

Did If the

Describe the circumstances (eg training sessions missed, games missed, signs and symptoms of concussion) Please refer to the list of signs and symptoms below to describe your concussion circumstances

How long did your symptoms last?

Signs and Symptoms and Concussion

SANFL/AFL CONCUSSION POLICY - The Sturt Football Club fully endorses the SANFL/AFL concussion policy and protocols. Should you sustain a TBI (Concussion) at training/matches you will be assessed by a member of the SFC Training Staff. If you exhibit ANY of the above signs/symptoms you will be referred to a Sports Doctor at our primary care providers (Sportsmed). From this point on, your concussion will be managed by the Doctor you consult. Our role is to guide you through the FOUR STAGE graded return to train/play process. You should be aware that the “21 Day Rule” is a MINIMUM timeframe. If you continue to exhibit symptoms, the time you have out will be longer. In addition, there are “modifying” factors applicable to the SANFL/AFL policy. These include the number of concussions you have had, the high symptom burden in the first few days after injury and the age of the athlete. In these cases, the graduated loading program will be conducted over a longer period of time by extending the number of days between progressions, or, increasing the number of days held at each Stage/Step of the graded return to train/play protocol. ALL CONCUSSED PLAYERS MUST SAFELY PROGRESS THROUGH EACH PHASE OF THE 4 STAGE, RETURN TO PLAY PROGRAM. This will be managed by the SFC Training Staff and your treating Doctor.