CONCUSSION WRITE-UP. MARITAL STATUS: Single Married Separated Divorced Widowed

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1 226 North President St. Jackson, MS Toll Free CONCUSSION WRITE-UP NAME: SOCIAL SECURITY #: PLACE OF BIRTH ADDRESS: CELL PHONE #: OTHER PHONE #: ADDRESS: MARITAL STATUS/INFORMATION MARITAL STATUS: Single Married Separated Divorced Widowed SPOUSE S NAME: SOCIAL SECURITY#: CHILDREN Page 1 of 6

2 EDUCATION School Name Graduate Year HIGH SCHOOL: Yes No COLLEGE: Yes No COLLEGE: Yes No GRADUATE/POST: Yes No GRADUATE/POST: Yes No NON-FOOTBALL EMPLOYMENT HISTORY FOOTBALL EMPLOYMENT HISTORY Page 2 of 6

3 FAMILY HISTORY Please identify anyone in your immediate family (parents, brothers, sisters) who has in the past or currently has experienced neurological cognitive problems of any time (no matter how minor or major) YOUR MEDICAL HISTORY Has Dementia been diagnosed? Yes No If so, when? Has Alzheimer s been diagnosed? Yes No If so, when? Has ALS been diagnosed? Yes No If so, when? Do you have headaches? Yes No If so, when? Are you forgetful? Yes No If so, when? Do you have memory loss? Yes No If so, when? Doctor Name: Phone #: CURRENT MEDICATIONS If you are currently taking any prescribed medications relating to cognitive problems, please list them below: Medication Dosage Prescribing Doctor For How Long Page 3 of 6

4 INJURY HISTORY Please provide as much detailed information as possible regarding the following: When and how many times can you recall, whether it was high school, college or the NFL, the following: (please include practices and games and try to give us approximate dates for each) High School/University/Team Name Dates 1. Getting your bell rung. 2. Getting knocked out. 3. Coming out feeling dizzy or dazed. 4. Concussion. 5. Loss of Consciousness. 6. Dinged. When do you believe you first told anyone associated with any of your teams in the NFL that you had experienced any of the problems mentioned above? 88 PLAN BENEFITS Have you applied for 88 Plan benefits under the Bert Bell/Pete Rozelle Retirement Plan? Yes No If so, When? Awarded When? Denied When? If you had an attorney assisting you with obtaining these benefits, please provide the following information: Attorney Name: Phone #: Attorney Page 4 of 6

5 List all worker compensation claims that have been filed on your behalf for ALL injuries including concussions. Page 5 of 6

6 Worker compensation claims CONTINUED Page 6 of 6

ADULT NEUROPSYCHOLOGICAL HISTORY

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