Athlete Concussion Questionnaire

This questionnaire is part of the Youth Football Concussion Awareness Project which is a joint project between the South West Regional Football Development Council, the West Australian Football Commission and Murdoch University, and aims to increase the awareness and management strategies of concussion in Youth Footballers. We thank you for your participation.

I am ...

I am ... Male Female
Age
Please select your location
How many years have you played Football?
Have you ever been concussed or had your 'bell rung' when playing Football?

Have you ever been concussed or had your 'bell rung' when playing Football? Yes No
For each of the following symptoms, please check "Yes" if you think it is a symptom of a concussion. Please check "No" if you think it is not a symptom of a concussion. If you don’t know, please check "Don’t Know".
Unusual Sense of Smell
Unusual Sense of Taste
Loss of Memory
Blurred Vision
Chest Pain
Dizziness
Confusion
Headache
Nosebleed
Blacked Out
Sharp Burning Pain in Neck
Feeling Sick
Numbness / Tingling in Arms or Hands
Weak Feeling when moving your Neck
Trouble Sleeping
Problems Studying or doing class work
True / False Questions (Please select "True" or "False" OR "Don’t Know" for the following statements):
An athlete who reports having a headache after a concussion will likely have other symptoms
A concussion only occurs when the athlete blacks out
A concussion requires the athletes to be taken out of the game or training right away
An athlete who shows any sign or symptom of concussion should not be allowed to return to play
Youth athletes should be allowed to return to play in a slow step-by-step way after having a concussion if they are symptom-free
Scenarios (Please check the box next to the answer you think is correct)
A youth footy player receives a direct blow to the side of his head from another player and falls to the ground. As he gets up, he experiences mild dizziness and has a headache. Should the player have continued to play footy in this situation?

A youth footy player receives a direct blow to the side of his head from another player and falls to the ground. As he gets up, he experiences mild dizziness and has a headache. Should the player have continued to play footy in this situation? Yes Maybe No
A youth footy player receives a hit to the head during training. As the player is looked at on the side of the oval, it is found that he is awake, had no loss of memory, feels fine at rest, and when he is asked to jog around the oval he has only a mild headache. Should the player return to play?

A youth footy player receives a hit to the head during training. As the player is looked at on the side of the oval, it is found that he is awake, had no loss of memory, feels fine at rest, and when he is asked to jog around the oval he has only a mild headache. Should the player return to play? Yes Maybe No
That concludes the survey.

If you would like to receive further information about Concussion or the Youth Football Concussion Awareness Project in the future please include your email address below.
Name
Email
Thank you for participating in this study

Athlete Concussion Questionnaire

Athlete Concussion Questionnaire

For each of the following symptoms, please check "Yes" if you think it is a symptom of a concussion. Please check "No" if you think it is not a symptom of a concussion. If you don’t know, please check "Don’t Know".

True / False Questions (Please select "True" or "False" OR "Don’t Know" for the following statements):

Scenarios (Please check the box next to the answer you think is correct)

That concludes the survey. If you would like to receive further information about Concussion or the Youth Football Concussion Awareness Project in the future please include your email address below.

Thank you for participating in this study

That concludes the survey.

If you would like to receive further information about Concussion or the Youth Football Concussion Awareness Project in the future please include your email address below.