Brain Health Information Survey

CONSENT

Person under 18?

In the case of a person under 18 years of age, please provide your full name as parent/guardian and sign below.

Parent/Guardian email

PARTICIPANT DETAILS

Participant Email *

Participant First (given) name *

Surname *

School/club/organisation?

Date of birth

What is your age? *

What is your gender? *

Private Health Fund Name

Private Health Number

Number on card (for child)

Extras private health cover?

GP or Club Physician name *

GP Clinic name *

GP Clinic Phone number *

GP or GP Clinic email

I consent for me or my child to have a quick brain health baseline test administered.

I understand that:

testing may include a survey about mental wellbeing and sleep, relevant medical history including previous concussions, Vestibuar-ocular assesment with NeuroFlex VR technology, Balance tests and Reaction time.
'Your Brain Health' may release the test results to your primary care physician (GP), neurologist, other treating physician, or any licensed healthcare professional that you nominate.
general information about the test data may be provided to your school/club health centre relevant staff member Director of Sport/Inclusion team members for the purposes of providing temporary academic modifications, if necessary. In the case of any impairment of concern or red flags, the school/club will be notified and advised to contact you to follow up with your GP/physician.
data from these tests can be used for research into brain health and concussion. All research data will remain secure, de-identified and completely anonymous and all research output will be cleared by a Human Research Ethics Committee.
all data is kept secure according to Australia Privacy Principles.

Signature of person/parent/guardian *

Draw signature|Type signatureClear

Today's Date *

Sport (if relevant)

If 'other', please name your sport

Grade/team/squad currently playing this season

Relevant Medical History

The survey below provides your health professionals with helpful information that can assist with best practice assessments and treatments in the event of a head knock or concussion. Please be advised this information is not compulsory.

Are you currently taking any form of medication?

YesNo

Please list them

Have you suffered a concussion before at any age?

At what age was your first concussion/head knock? *

What activity were you involved in when you suffered your first concussion/head knock? *

How many concussions to you think you have sustained?

When was your most recent concussion/head knock? (Month/Year) *

What activity were you involved in when you suffered your most recent concussion/head knock?

Have you fully recovered from your last concussion? *

If you have recovered from this concussion , how long was the recovery time (return to sport/study/work) for your most recent concussion/head knock?

Sleep (Abbreviated Athlete Sleep Screening Questionnaire)

During the past week how many hours of actual sleep did you get at night? (This may be different from the number of hours you spend in bed.) *

During the recent past, how long has it usually taken you to fall asleep each night? *

Longer than 60 munities31-60 minutes16-30 minutes15 minutes or less

How often do you have trouble staying asleep? *

Five to seven times a weekThree to four times a weekOnce or twice a weekNever

During the recent past, how often have you taken medicine to help you sleep? (prescribed or over-the-counter) *

Five to seven times a weekThree or four times a weekOnce or twice a weekNever

Sleep Screen Score *

A higher sleep disorder score (SDS) indictaes a greater likelihood of a clinical sleep disorder:

0-4 (Normal)

5-7 (Mild)

8-10 (Moderate)

11-17 (Severe)

Symptom Evaluation at this point in time

The survey below provides your health professionals with helpful information that can assist with best practice assessments and treatments in the event of a head knock or concussion. Please be advised this information is not compulsory.

Total Symptom Score /132

Do your symptoms get worse with physical activity? *

Do your symptoms get worse with mental activity? *

If 100% is feeling perfectly normal, what percent of normal do you feel? *

If not 100%, why?

Payment $65 AUD *