ARLINGTON HIGH SCHOOL ATHLETIC TRAINING PHYSICIAN REFERRAL CHECKLIST

Day Of Injury Referral

• Deterioration of neurologic function.*
• Decreasing level of consciousness.*
• Decrease or irregularity in pulse.*
• Decrease or irregularity in respirations.*
• Unequal, dilated, or unreactive pupils.*
• Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding.*
• Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation. *
• Seizure activity.*

*Requires that the athlete be transported immediately to the nearest emergency department.

• Cranial nerve deficits.
• Increase in blood pressure.
• Loss of consciousness on the field.
• Amnesia lasting longer than 15 minutes.
• Vomiting.
• Motor deficits subsequent to initial on-field assessment.
• Sensory deficits subsequent to initial on-field assessment.
• Balance deficits subsequent to initial on-field assessment.
• Cranial nerve deficits subsequent to initial on-field assessment.
• Post-concussion symptoms that worsen.
• Additional post-concussion symptoms as compared with those on the field.
• Athlete is still symptomatic at the end of the game.

Delayed Referral

After the day of injury

• Any of the findings in the day-of-injury referral category.
• Post-concussion symptoms worsen or do not improve over time.
• Increase in the number of post-concussion symptoms reported.