Self Assessment

BCI IS AN INNOVATIVE, PHYSICIAN-LED, MULTI-DISCIPLINARY SPORT-RELATED CONCUSSION, PERFORMANCE MEDICINE AND REHABILITATION CLINIC FOUNDED ON OVER TWO DECADES OF APPLIED SPORT INJURY RESEARCH AND CLINICAL EXPERIENCE.

BCI Self-Referral Online Questionnaire

    Are you currently experiencing any concussion-like symptoms?YesNo

    Was your concussion sustained while participating in a sporting activity?YesNo

    Please be advised that our program is specific to sport or recreation-related concussions only. It is important to us that you receive the most appropriate care for your injury possible. Given that your current injury is not sport-related, we recommend that you speak with your family physician about more suitable management options.

    Did your concussion occur within the last 30 days?YesNo

    You may be eligible to access our Acute Sport-Related Concussion Self-Referral Program. Please complete and submit the questionnaire below and someone from our team will contact you to discuss your case and book an appointment.

    Demographic Information

    First Name(*)

    Last Name(*)

    Date of Birth(*)

    Sex(*)MaleFemaleOther

    Email(*)

    Phone(*)

    Address(*)

    City(*)

    Province(*)

    Postal Code(*)

    Injury Details

    Date of Concussion(*)

    Activity at time of concussion(*)

    Were you experiencing any unresolved concussion-like symptoms at the time you sustained your current injury?(*)YesNo

    Disclaimer (*)

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    Did your concussion occur within the last 12 months?YesNo

    You may be eligible to access our Persistent Concussion-Like Symptom Self-Referral Program. This program is highly individualized and includes a comprehensive multi-disciplinary neurological assessment followed by an immersive, integrated 2-week multi-modal neuro-rehabilitation program designed to help you recovery from your injury. Please complete the questionnaire below and someone from our team will contact you to discuss your case and book an appointment.

    Demographic Information

    First Name(*)

    Last Name(*)

    Date of Birth(*)

    Sex(*)MaleFemaleOther

    Email(*)

    Phone(*)

    Address(*)

    City(*)

    Province(*)

    Postal Code(*)

    Injury Details

    Date of Concussion(*)

    Activity at time of concussion(*)

    Were you experiencing any unresolved concussion-like symptoms at the time you sustained your current injury?(*)YesNo

    Disclaimer (*)

    (*)

    (*)

    (*)

    Are you an athlete between the ages of 10 and 40 years old?YesNo

    You may be eligible for our annual high-performance sport concussion program, which includes a comprehensive pre-season baseline neurological assessment and direct access to the clinic without a referral for any sport-related concussion or musculoskeletal injury sustained during your athletic season. To be considered for this service, please click on the "Pre-season baseline assessment appointment link.

    Our annual high-performance sport concussion program is currently designed for healthy, active individuals participating in sport or recreation activities aged 10-40 years old. If you would like to discuss further options for you, please contact our clinic at 587-391-9840 or email: info@bciconcussion.ca.