1. Athlete’s Name: Athletic Trainer: Phone:
Children’s Hospital Colorado Concussion Program
Athlete’s Name: Athletic Trainer: Phone:
Stage
Activity
Functional Exercise
What Athlete Completed
Date Completed
Relative rest
Easy walking such as a short walk around the neighborhood 1
Light aerobic activity
15-20 minutes, No resistance
Examples: brisk walking, stationary cycling, 2
Non-contact sport-specific activity
30-45 minutes, No weight lifting, No head contact,
Examples: skating in hockey, dribbling in soccer 3
Non-contact drills
1-2 hours, Progression to more complex drills, may start progressive resistance training
Examples: blocking pads in football 4
Full-contact practice
Following MEDICAL CLEARANCE, participate in normal training activities; full exertion, full pads and contact 5
Return to play
Competitive game play and tournaments
To proceed to next stage, athlete must remain symptom free for 24 hours. If symptoms reemerge, return to previous stage after 24 hours of rest.