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 URI Sports Medicine
CONCUSSION EVALUATION

Athlete's Name: Date: ei z 3 I )

Evaluator: lc e l S ci Pre or Post Injury: o n -0-
Page 1 (SAC)

Standardized Assessment of Concussion: (SAC)

1. Orientation:
Month: 0
Date: 0 CU
Day of wk: 0 0
Year: 0
Time: (within 1 hr) 0 0
Orientation Total Score 5 /5

2. Immediate Memory: Read list for each trail Athlete does not have to list in order to gain pt
(all 3 trails are completed regardless of score on trail I &2: score equals sum of all 3 trails)
List Trail 1 Trail 2 Trail 3
Elbow 0O 0 190
Apple 0 Qj 0 o6)
Carpet 00
Saddle 0 0 08
Bubble 0W 00 00
Total 5 5
Immediate Memory Total Score 6 / 15
(do not informthe subject that delay recall will be lessed)

3. Concentration:
Digits Backwards: (If correct, go to next string. If incorrect, read Vail 2. Stop after incorrect on both trails)

4-9-3 6-2-9 0
3-8-1-4 3-2-7-9 00
6-2-9-7-1 1-5-2-8-6 G1
7-1-8-4-6-2 5-3-9-1-4-8 01
Months in Reverse Order (correct for 1 pt)
Dec-Nov-Oct-Sept-Aug-Jul
June-May-April-March-Feb-Jan o0
Concentration Total Score: 3 /5
 URI Sports Medicine
CONCUSSION EVALUATION
Page 2 {SAC}

4. Delayed Recall
Elbow 00
Apple
Carpet
Saddle o
Bubble 0G1
Delayed Recall Total Score: 5 /5

Summary of Total Scores:

Orientation: 5 /5
Immediate Memory: 15 / 15
Concentration: 3 /5
Delayed Recall /5

Overall Total Score: 2.B / 30

Post Concussion only for below

Neurological Screening:
Loss of Consciousness (presence, duration)
Recollection of Injury (Pre- or Post-Traumatic Amnesia)
Strength:
Sensation:
Coordination:
*Exertional Maneuvers: (when appropriate)
5 jumping jacks 5 push ups
5 sit ups 5 knee bends

Athlete's Signature & Date i C.) / 5 )

Notes:
 URI Sports Medicine
CONCUSSION EVALUATION

Athlete's Name. Date: ``t 5 11

Evaluator Ke scy C Pre or Post Injury: Pest

Balance Error Scoring System: (BESS)

Clinical Test Battery

-Six 20 Second Trails: (eyes closed with each trail)
-Using Three Different Stances (Double, Single,
Tandem)
-Two Different Surfaces (Firm / Foam)

Recorded Errors:
-Hands lifted off iliac crest
-Opening eyes
-Step, stumble, or fall
-Moving into >30 degrees of hip flexion or abduction
-Remaining out of testing position for >5 seconds

Position One: (Double Firm) Score: 0

Position Two: (Single Firm) Re Score:

(Circle wh leg using non dominant leg)

Position Three: (Tandem Firm) Score: 0

Position Four: (Double Foam) Score: 0

Position Five: (Single Foam) R4L Score: 1

(Same let as aboveusing non dominant le(2)

Position Six: (Tandem Foam) Score:

Total Score: I it-

Athlete's Signature late: "15