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Appendix 3: Head Injury Advice form (sample)

Appendix 3: Head Injury Advice form (sample). Club:…………………………………………………………….. Players name:…………………………………………………. Date / time of injury:………………………………………………………… Brief details of injury:……………………………………………………….. First Aider:…………………………………………………………………… HEAD INJURY ADVICE FORM

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Appendix 3: Head Injury Advice form (sample)

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  1. Appendix 3: Head Injury Advice form (sample) • Club:…………………………………………………………….. • Players name:…………………………………………………. • Date / time of injury:………………………………………………………… • Brief details of injury:……………………………………………………….. • First Aider:…………………………………………………………………… • HEAD INJURY ADVICE FORM • The person named above sustained a head injury during the match/training session. They have been treated at pitchside but should be observed closely for the next 48 hours by a responsible adult as Head Injury / Concussion problems may not become apparent for some time after the original incident. • They should eat, drink and sleep as normal but should avoid alcohol, drugs and other sedatives. They should not drive, ride bikes or operate machinery if they feel in any way unwell. • The following are often experienced after Head Injury: • Mild headache • Nausea (feeling sick) • Mood changes, irritability • Loss of appetite • Disturbed sleep • Lack of concentration and forgetfulness • These should settle down in the days following the incident but medical advice should be obtained from a General Practitioner or NHS Direct (tel: 0845 46 47) if there are any concerns during this time. • If any of the following are noted the person should be taken to the nearest Accident and Emergency Department immediately: • Unconsciousness, persistent drowsiness, difficulty waking, unusual sleep patterns • Slurred speech, nonsense speech, difficulty speaking or understanding • Vomiting • Fits, convulsions, sudden collapse or fainting • Blurred vision, double vision or any other problems of eyesight • Deafness, persistent noise, ringing or any other problems of hearing • Severe headache • Problems of balance, weakness, tingling or numbness in limbs • Bleeding or discharge of clear fluid from ears or nose (not simple nosebleed) • PLEASE NOTE: In accordance with governing body Guidelines, this person will not be allowed to train or play for a period of……………….. and / or only after clearance by a suitable Doctor. • A copy of this form must be retained in the clubs accident records. Any player issued with more than 1 Head Injury form MUST NOT return to play without specific medical dispensation. TO BE RETAINED IN CLUB RECORDS

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