Concussion Rehabilitation Assessment
Use this concussion rehabilitation assessment template to document symptom burden, balance, vestibular findings, and cognitive screening in one structured review. It helps you track recovery trends and support return-to-activity decisions.
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Built for: Sports Medicine · Physical Therapy · School Health · Occupational Health
Overview
This concussion rehabilitation assessment template is built to document the core elements clinicians use when monitoring recovery after a concussion: symptom burden, balance and vestibular screening, cognitive screening, and return-to-activity readiness. It gives you a repeatable structure for comparing visits, noting whether a baseline is available, and recording whether prior concussion history may affect recovery.
Use it when you need a clear, defensible snapshot of current status during follow-up care, before advancing activity, or when symptoms are lingering and you need to separate improving findings from new or worsening deficits. The template is especially useful in sports medicine, physical therapy, school health, and occupational health settings where multiple people may review the same record.
Do not use it as a substitute for urgent medical evaluation when red-flag symptoms, neurological deterioration, or other serious concerns are present. It is also not meant to replace a full neurological exam, imaging decisions, or specialist referral when those are clinically indicated. The value of the template is consistency: it helps you capture the same observable findings each time so recovery trends, symptom provocation, and readiness decisions are easier to interpret.
Standards & compliance context
- This template supports documentation practices commonly used in concussion care under general clinical standards and return-to-activity protocols, but it does not replace a licensed clinician’s judgment.
- The balance, vestibular, and cognitive fields align with the type of structured assessment often expected in sports medicine, rehabilitation, and occupational health workflows.
- If the assessment is used in a school, workplace, or athletic program, follow the organization’s concussion policy, referral pathway, and clearance requirements.
- When symptoms suggest a more serious injury or neurological decline, escalate according to local emergency and clinical protocols rather than relying on this template alone.
- For return-to-play or return-to-work decisions, pair this record with any applicable governing body, insurer, or employer requirements.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Assessment Details
This section matters because it anchors the visit in time, context, and prior history so later findings can be interpreted correctly.
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Assessment type
Identify whether this is a baseline, acute, follow-up, or clearance-related assessment.
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Days since injury
Enter the number of days since the suspected or confirmed concussion event.
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Assessment setting
Document where the assessment was performed.
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Baseline comparison available
Indicate whether pre-injury baseline testing or prior assessment results are available for comparison.
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Relevant prior concussion history documented
Confirm whether prior concussion history and recovery pattern have been reviewed.
Symptom Burden
This section matters because symptom severity and count are the clearest indicators of whether recovery is progressing or stalling.
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Overall symptom severity score
Record the total symptom severity score using the clinic’s chosen concussion symptom scale.
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Number of symptoms reported
Record the total number of symptoms currently reported by the patient.
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Headache severity
Rate headache severity during the assessment.
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Dizziness or balance-related symptom severity
Rate dizziness, vertigo, or imbalance symptoms.
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Light sensitivity severity
Rate photophobia or light sensitivity symptoms.
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Noise sensitivity severity
Rate phonophobia or noise sensitivity symptoms.
Balance and Vestibular Screening
This section matters because balance and vestibular deficits often show up in observable tasks even when the patient seems stable at rest.
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Single-leg stance maintained without loss of balance
Observe whether the patient can maintain single-leg stance for the clinic-defined duration without stepping, swaying excessively, or requiring support.
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Tandem gait performed without deviation
Assess whether tandem gait is completed without stepping off line, pausing, or needing assistance.
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Romberg stance stability
Rate postural stability during Romberg stance or equivalent balance testing.
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Vestibular symptom provocation during testing
Indicate whether balance or head-movement testing provoked dizziness, nausea, blurred vision, or symptom worsening.
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Gait observed as normal and safe
Confirm whether gait is steady, safe, and appropriate for the environment without assistive support.
Cognitive Screening
This section matters because orientation, recall, and attention checks help reveal lingering cognitive effects that influence safe activity progression.
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Orientation intact
Confirm orientation to person, place, time, and situation.
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Immediate recall performance
Record the number of words or items correctly recalled immediately, based on the selected screening tool.
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Attention and concentration adequate for screening
Indicate whether the patient could sustain attention and complete cognitive tasks without excessive prompting or distraction.
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Delayed recall performance
Record delayed recall results using the clinic’s chosen cognitive screening method.
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Cognitive symptoms worsened during screening
Document whether screening triggered headache, fogginess, slowed thinking, or other symptom worsening.
Return-to-Activity Readiness
This section matters because it ties the findings to a practical decision about whether activity can advance or should remain restricted.
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Symptoms at rest are minimal or absent
Confirm whether symptoms at rest are minimal enough to support progression in the return-to-activity plan.
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Symptoms do not worsen with light activity
Indicate whether the patient tolerated light physical or cognitive activity without symptom exacerbation.
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Return-to-activity recommendation
Select the current recommendation based on symptoms, balance, and cognitive findings.
How to use this template
- 1. Enter the assessment details first, including the assessment type, days since injury, setting, whether a baseline comparison is available, and any relevant prior concussion history.
- 2. Record symptom burden using the same scale at each visit so overall severity, number of symptoms, and specific complaints such as headache, dizziness, light sensitivity, and noise sensitivity can be compared over time.
- 3. Complete the balance and vestibular screening by documenting single-leg stance, tandem gait, Romberg stability, symptom provocation, and whether gait remained normal and safe during testing.
- 4. Perform the cognitive screening in the same order each time and note orientation, immediate recall, attention and concentration, delayed recall, and whether symptoms worsened during the tasks.
- 5. Review the return-to-activity section last, then document whether symptoms are minimal at rest, whether light activity worsens them, and what activity recommendation follows from the findings.
Best practices
- Use the same symptom scale at every visit so changes in severity are easier to interpret.
- Document observable performance, not just impressions, especially for gait, stance, and recall tasks.
- Note whether symptoms were present before testing and whether they worsened during specific maneuvers.
- Record the presence or absence of a baseline comparison because it changes how you interpret recovery progress.
- Flag any prior concussion history that may affect symptom duration or return-to-activity planning.
- Treat balance or vestibular symptom provocation as a meaningful finding even when the patient appears otherwise stable.
- Photograph or attach supporting notes only when your workflow allows it and when privacy rules permit, but never rely on memory after the visit.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use a concussion rehabilitation assessment template?
It is typically used by athletic trainers, physical therapists, occupational therapists, school health staff, and other qualified clinicians involved in concussion recovery. It is also useful for return-to-play or return-to-work decisions when a structured record is needed. The template is not a diagnosis tool by itself; it supports clinical judgment with consistent documentation.
When should this assessment be completed?
Use it after a suspected or confirmed concussion, during follow-up visits, and before advancing activity levels. It is especially helpful when symptoms are changing, when balance or vestibular issues are present, or when a baseline comparison is available. It should not replace urgent evaluation if red-flag symptoms or worsening neurological signs are present.
What does this template help document that a free-text note might miss?
It captures symptom severity, number of symptoms, balance findings, vestibular provocation, and basic cognitive screening in a repeatable format. That makes it easier to compare visits and spot non-conformance with expected recovery patterns. It also reduces the chance that key return-to-activity criteria are skipped.
Does this template support return-to-play or return-to-work decisions?
Yes, it is designed to inform return-to-activity readiness by recording whether symptoms are minimal at rest and whether light activity worsens them. The final recommendation field helps document the decision and any restrictions or next steps. Final clearance should still follow the clinician’s protocol and applicable organizational policy.
How often should the assessment be repeated?
Frequency depends on the care plan, symptom severity, and the pace of recovery. Many teams use it at baseline if available, then at each follow-up until symptoms and functional findings stabilize. Repeating the same template over time is more useful than switching formats mid-recovery.
What are common mistakes when using this template?
A common pitfall is recording only a general impression instead of specific symptom scores and observable balance or gait findings. Another is treating a single normal screening as proof of full recovery when symptoms still worsen with activity. It is also important to note whether a baseline comparison exists and whether prior concussion history was documented.
Can this template be customized for sports, school, or workplace use?
Yes, the template can be adapted to match the setting, whether that is an athletic sideline, clinic, school health office, or occupational health visit. You can add organization-specific return-to-activity steps, referral triggers, or clearance requirements. Keep the core fields intact so recovery trends remain comparable across visits.
How does this compare with an ad-hoc concussion note?
An ad-hoc note often misses one or more domains, making it harder to compare visits or defend a return-to-activity decision. This template standardizes the same core checks each time, including symptoms, balance, vestibular response, and cognition. That consistency is useful for handoffs, audits, and follow-up planning.
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