Vanderbilt Sports Medicine
Patient: _______________________________
Date: _________________
Please excuse the above named patient from school today due to a medical appointment.
The student has sustained a concussion and is currently under the care of his/her
physician. S/he is not permitted to participate in any contact sport activity until formally
cleared by his/her physician.
Please consider the following concussion-related recommendations:
Gym Class Recommendations:
___No Gym Class
___Restricted gym class as specified _________________________________
Recommended Academic accommodations:
___Untimed tests
___Open note/Open book or Oral tests
___Tutoring
___Reduced Workload when possible
___15 minute rest breaks from every ___ hour(s)
___Modified/reduced homework assignments
___Extended time on homework/projects
___Tape record class lectures
Other recommendations___________________________________________
________________________________M.D.
Orthopaedic Institute
MCE, S. Twr, Ste 3200
Nashville, TN 37232
(615) 322-7878
Date: _____________________
Orthopaedics at Cool Springs
324 Cool Springs Blvd
Franklin, TN 37067
(615) 790-4280
Bone & Joint
206 Bedford Way
Franklin, TN 37064
(615) 790-3290
Bowling Green, KY
Murray, KY
Paducah, KY
877-826-3976