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What is your last name?
   
 
 
 
What Position do you typically play?
   
 
 
 
What year are you in college?
 
Freshman
 
Sophomore
 
Junior
 
Senior
 
Graduate Student
 
Other
 
 
 
 
What is your age?
 
18
 
19
 
20
 
21
 
22
 
23
 
24 or older
 
 
 
Have you ever had a concussion in the past?
 
Yes
 
No
 
 
 
If yes to the previous question when did the concussion occur?
   
 
 
 
If yes to question #5 was the concussion soccer related?
   
 
 
 
Have you sustained a concussion playing soccer this season?
 
Yes
 
No
 
 
 
If yes to #8 when did the concussion occur?
   
 
 
 
If yes to #8 how did the concussion occur?
 
Head to ground contact
 
Contact with a soccer ball
 
contact with another person
 
Head to head collision while heading the soccer ball
 
Other
 
 
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