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Acute Concussion Evaluation

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Acute Concussion Evaluation (Ace) Patient Name:PhysiciAn/cliniciAn office version DOB: Age: Gerard Gioia, PhD1 & Micky Collins, PhD2 1Children s National Medical Center Date: ID/MR# 2University of Pittsburgh Medical Center A. Injury Characteristics Date/Time of Injury Reporter: __Patient __Parent __Spouse __Other________ 1. Injury Description 1a. Is there evidence of a forcible blow to the head (direct or indirect)? __Yes __No __Unknown 1b. Is there evidence of intracranial injury or skull fracture? __Yes __No __Unknown 1c.

ofice or (2) refer them to a specialist. Serial evaluation of the concussion is critical as symptoms may resolve, worsen, or ebb and low depending upon many factors (e.g., cognitive/physical exertion, comorbidities). Referral to a specialist can be particularly valuable to help manage certain aspects of the patient’s condition.

  Evaluation, Acute, Concussion, Acute concussion evaluation

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