Health.mil/TBICoE Page 1 of 14
MACE 2 - Military Acute Concussion Evaluation
Revised 03/2021
Service Member Name: _____________________________
DoDI/EDIPI/SSN: ________ Branch of Service & Unit: _____
Date of Injury: ___________ Time of Injury: _____________
Examiner: _______________________________________
Date of Evaluation: _______ Time of Evaluation: __________
RED FLAGS
Use MACE 2 as close to time of injury as possible.
Military Acute Concussion Evaluation
Defer MACE 2 if any red ags are present. Immediately
consult higher level of care and consider urgent evacuation
according to evacuation precedence/Tactical Combat
Casualty Care (TCCC).
Evaluate for red flags in patients with Glasgow Coma Scale (GCS) 13-15.
❏
Deteriorating level
of consciousness
❏
Double vision
❏
Increased restlessness,
combative or agitated
behavior
❏
Repeat vomiting
❏
Results from a structural
brain injury detection device
(if available)
❏
Seizures
❏
Weakness or tingling
in arms or legs
❏
Severe or worsening
headache
MACE 2
❏
Negative for all red ags
Continue MACE 2, and observe for red ags throughout evaluation.
Purpose: MACE 2 is a multimodal tool that assists providers in the assess-
ment and diagnosis of concussion. The scoring, coding and steps to take after
completion are found at the end of the MACE 2.
Timing: MACE 2 is most effective when used as close to the time of injury as
possible. The MACE 2 may be repeated to evaluate recovery.
Health.mil/TBICoE Page 2 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
C. Record the type of event.
Check all that apply:
Fall
Assault
Explosion/blast
Estimated distance _____
Motor vehicle
crash
Other
______________
Fragment
Blunt object Gunshot woundSports injury
MILITARY ACUTE CONCUSSION SCREENING
Complete this section to determine if there was an injury event
AND an alteration of consciousness or memory.
1. Description of Incident
A. Record the event as described by the service member or
witness.
Use open-ended questions to get as much detail as possible.
Key questions:
❏
Can you tell me what you
remember?
❏
What happened?
❏
Who were you last with?
D. Was there a blow or jolt to the head?
❏
Did your head hit any objects?
❏
Did any objects strike your head?
❏
Did you feel a blast wave? (A blast wave that is felt
striking the body or head is considered a blow to the
head.)
❏
Did you have a head acceleration or deceleration?
YES NO UNKNOWN
B. Observable Signs
❏
Lying motionless on the ground
❏
Slow to get up after a direct
or indirect blow to the head
❏
Disorientation, confusion,
or an inability to respond
appropriately to questions
❏
Blank or vacant look
❏
Balance difculties,
stumbling, or slow labored
movements
❏
Facial injury after head
trauma
❏
Negative for all observable
signs
At the time of injury were any of these observable signs witnessed?
Visual clues that suggest a possible concussion include:
Health.mil/TBICoE Page 3 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
Common symptoms after a concussion are listed below. For this event, check all
that apply.
❏
Headache
❏
Dizziness
❏
Memory problems
❏
Balance problems
❏
Nausea/vomiting
❏
Difculty concentrating
❏
Irritability
❏
Visual disturbances
❏
Ringing in the ears
❏
Other _______________
❏
Negative for all symptoms
3. Symptoms
2. Alteration of Consciousness or Memory
Key questions:
❏
Were you dazed, confused,
or did you “see stars”
immediately after the event?
❏
Did you feel like you were
in a fog, slowed down, or
“something was not right”?
A. Was there alteration of
consciousness (AOC)?
AOC is temporary confusion
or “having your bell rung.”
YES NO
If yes, for how long?
seconds
minutes
UNKNOWN
B. W as there loss of
consciousness (LOC)?
Key questions:
❏
Did you pass out or black out?
❏
Is there a period of time you
cannot account for?
LOC is temporarily passing
out or blacking out.
YES NO
If yes, for how long?
seconds
minutes
UNKNOWN
C. W as there any post
traumatic amnesia (PTA)?
Key questions:
❏
Is there a period of time you
cannot account for?
❏
What is the last thing you
remember before the event?
❏
What is the rst thing you
remember after the event?
PTA is a problem remembering
part or all of the injury events.
YES NO
If yes, for how long?
seconds
minutes
UNKNOWN
Tips for assessment:
❏
Ask witness to verify AOC,
LOC or PTA and estimate
duration.
D. W as the AOC, LOC or PTA
witnessed?
YES NO
If yes, for how long?
seconds
minutes
UNKNOWN
Health.mil/TBICoE Page 4 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
CONCUSSION SCREENING RESULTS (Possible Concussion?)
Was there a blow or jolt to the head (1D)
AND
ANY alteration of consciousness or memory? (2A,2B,2C,or 2D)
NEGATIVE
CONCUSSION SCREEN:
1. Stop MACE 2.
2. Initiate 24 hour-rest period, if
deployed. During rest, avoid
activities that worsen symptoms.
Follow up with service member in
accordance with the Progressive
Return to Activity (PRA).
3. Communicate findings to line
leadership.
4. Document and code findings in
electronic health record (EHR).
YES (to both)
NO ( to either
or both)
4. History
A. During the past 12 months, were you diagnosed with
a concussion, not counting this event?
YES NO
If yes, how many?
UNKNOWN
B. History of diagnosed/treated headache disorder or migraine.
YES NO
C. History of depression, anxiety, or other behavioral health concerns.
YES NO
POSITIVE
CONCUSSION SCREEN:
1. Continue MACE 2.
2. Complete evaluation before
prescribing rest.
3. Communicate findings to line
leadership.
4. Document and code findings in
electronic health record (EHR).
Health.mil/TBICoE Page 5 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
List A
Correct Correct Correct
Trial 1
Jacket
10 0
Pepper
10 0
Arrow
10 0
Cotton
10 0
Movie
1
1
1
1
1 1
1
1
1
1
10 0
0
0
0
0
0
Trial 2 Trial 3
Incorrect Incorrect Incorrect
IMMEDIATE MEMORY TOTAL SCORE
COGNITIVE EXAM
5. Orientation
Score one point for each correct response.
6. Immediate Memory
Choose one list (A-F below) and use that list for the remainder
of the MACE 2.
Read the script for each trial and then read all ve words. Circle the
response for each word for each trial. Repeat the trial three times,
even if the service member scores perfectly on any of the trials.
Trial 1 script: Read the script exactly as written.
■
“ I am going to test your memory. I will read you a list of words
and when I am done, repeat back to me as many words as you can
remember, in any order.”
Trials 2 and 3 script: Read the script exactly as written.
■
“ I am going to repeat that list again. Repeat back to me as many words
as you can remember, in any order, even if you said them before.”
Immediate Memory Alternate Word Lists
List B
Dollar
Mirror
Honey
Saddle
Anchor
List C
Finger
Blanket
Penny
Lemon
Insect
List D
Baby
Perfume
Monkey
Sunset
Iron
List E
Candle
Sugar
Paper
Sandwich
Wagon
List F
Elbow
Carpet
Apple
Saddle
Bubble
ORIENTATION TOTAL SCORE
Ask This Question Incorrect Correct
0 1
“What month is this?”
0 1
“What is the date or day of the month?”
0 1
“What day of the week is it?”
0 1
“What year is it?”
0 1
“What time do you think it is?”
Correct response must be within one hour of actual time.
15
5
Health.mil/TBICoE Page 6 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
NEUROLOGICAL EXAM
7. Speech Fluency
❏
Speech should be uid and
effortless – n o pauses or
unnatural breaks.
– Stuttering or struggling
to speak is abnormal.
Normal
Abnormal
8. Word Finding
❏
Assess difculties with word nding:
– Difculty in coming up with the
name of an object or grasping to
nd words is abnormal.
Normal
Abnormal
❏
Assess grip strength. Grip strength
should be strong and equal bilaterally.
– Unequal or weak grip strength
is abnormal.
9. Grip Strength
Normal
Abnormal
10. Pronator Drift
❏
Direct service member to stand with
eyes closed and arms extended
forward, parallel to the ground with
palms up. Assess for ve to 10
seconds:
– Any arm or palm drift is abnormal.
Normal
Abnormal
❏
Remove shoes if possible. Have
service member stand on one leg,
arms across chest, hands touching
shoulders, eyes open initially. Once
service member is balanced, have
them close their eyes and time for 15
seconds how long they can maintain
their balance. Repeat test with
opposite leg.
– Loss of balance on either leg before
eight seconds is abnormal.
11. Single Leg Stance
Normal
Abnormal
Health.mil/TBICoE Page 7 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
NEUROLOGICAL EXAM - Continued
NEUROLOGICAL
EXAM RESULTS
(Questions 7-14)
All Normal
Any Abnormal
12. Tandem Gait
❏
Remove shoes if possible. Have
service member take six steps one
foot in front of the other, heel-to-toe,
with arms at side
- Stumbling or shifting feet is
Normal
Abnormal
13. Pupil Response
❏
Pupils should be round, equal in
size and briskly constrict to a direct,
bright light.
- Unequal pupil size, dilation or
constriction delay is abnormal.
Normal
Abnormal
❏
Both eyes should smoothly track your
nger side-to-side and up and down.
- Unequal, irregular or delayed eye
tracking is abnormal.
14. Eye Tracking
Normal
Abnormal
15. Concentration
A. Reverse Digits
Read the script and begin the trial by reading the rst string
of numbers in Trial 1.
COGNITIVE EXAM
Circle the response for each string.
■
If correct on string length of Trial 1, proceed to the next longer
string length in the same column.
■
If incorrect on string length of Trial 1, move to the same string
length of Trial 2.
■
If incorrect on both string lengths in Trials 1 and 2, STOP
and record score as zero for that string length. Record total
score as sum of previous correct trials.
Health.mil/TBICoE Page 8 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
15. C oncentration - Continued
A. Reverse Digits
Script: Read the script exactly as written.
■
“ I am going to read you a string of numbers. When I am
finished, repeat them back to me backward. That is, in
reverse order of how I read them to you. For example,
if I said 7 - 1 - 9, then you would say 9 - 1 - 7.”
COGNITIVE EXAM - Continued
Trial 1 Trial 2
List B
5-2-6 4-1-5
1-7-9-5
4-9-6-8
4-8-5-2-7
6-1-8-4-3
8-3-1-9-6-4 7-2-7-8-5-6
Trial 1 Trial 2
List C
1-4-2 6-5-8
6-8-3-1
3-4-8-1
4-9-1-5-3
6-8-2-5-1
3-7-6-5-1-9 9-2-6-5-1-4
Trial 1 Trial 2
List D
7-8-2 9-2-6
4-1-8-3
9-7-2-3
1-7-9-2-6
4-1-7-5-2
2-6-4-8-1-7 8-4-1-9-3-5
Trial 1 Trial 2
List E
3-8-2 5-1-8
2-7-9-3
2-1-6-9
4-1-8-6-9
9-4-1-7-5
6-9-7-3-8-2 4-2-7-9-3-8
Trial 1 Trial 2
List F
2-7-1 4-7-9
1-6-8-3
3-9-2-4
2-4-7-5-8
8-3-9-6-4
5-8-6-2-4-9 3-1-7-8-2-6
Trial 1
List A
4-9-3 6-2-9
3-8-1-4 3-2-7-9
6-2-9-7-1 1-5-2-8-5
7-1-8-4-6-3 5-3-9-1-4-8
Trial 2
(if Trial 1 is incorrect)
Incorrect Correct
0
0
0
0
1
1
1
1
REVERSE DIGITS SCORE (15A)
4
Concentration Alternate Number Lists
Note: Use the same list (A-F) that was used in Question 6.
Health.mil/TBICoE Page 9 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
B. Months in Reverse Order
Script: Read the script exactly as written.
■
“ Now tell me the months of the year in reverse order.
Start with the last month and go backward.
So you’ll say: December, November…Go ahead.”
16. Delayed Recall
Read the script and circle the response for each word.
Do NOT repeat the word list.
Note: Use the same list (A-F) that was used in
Script: Read the script exactly as written.
■
“ Do you remember that list of words I read a few minutes earlier?
I want you to tell me as many words from that list as you can remember.
You can say them in any order.”
COGNITIVE EXAM - Continued
15. Concentration - Continued
Correct Response:
Dec – Nov – Oct – Sep – Aug – Jul –
Jun – May – Apr – Mar – Feb – Jan
MONTHS IN REVERSE ORDER
(15B)
ALL months in
reverse order
Incorrect Correct
0 1
1
CONCENTRATION TOTAL SCORE
Sum of scores:
15A (0-4 points) and 15B (0 or 1 point)
5
Delayed Recall Alternate Word Lists
DELAYED RECALL TOTAL SCORE
5
List B
Dollar
Mirror
Honey
Saddle
Anchor
List C
Finger
Blanket
Penny
Lemon
Insect
List D
Baby
Perfume
Monkey
Sunset
Iron
List E
Candle
Sugar
Paper
Sandwich
Wagon
List F
Elbow
Carpet
Apple
Saddle
Bubble
List A
Jacket
0 1
0 1
0 1
0 1
0 1
Arrow
Pepper
Cotton
Movie
Incorrect Correct
Health.mil/TBICoE Page 10 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
A. Baseline symptoms. Record headache, dizziness, nausea and fogginess
(HDNF), on zero to 10 scale prior to screening.
B. Smooth pursuits
. Service member and examiner are seated. Hold
ngertip three feet from patient. Service member focuses on
ngertip target as examiner moves ngertip smoothly horizontally
one and a half feet right and left of midline at rate requiring two
seconds to go fully from left to right and right to left. Perform
twice. Repeat in vertical direction one and a half feet above and
one and a half feet below midline up and down, moving eyes two
seconds fully up and two seconds down. Perform twice. Record
HDNF on a zero to 10 scale.
C. Saccades
. Service member and examiner are seated.
1) H orizontal saccades:
Hold two ngertips horizontally at a
distance of three feet from service member, and one and a
half feet left and right of midline so service member gazes 30
degrees left and right. Service member moves eyes as quickly
as possible from point to point. Perform 10 times. Record
HDNF on a zero to 10 scale.
2) Vertical saccades:
Repeat with two ngertips vertically three
feet from service member, and one and a half feet above and
below midline so service member gazes 30 degrees upward
and downward. Service member moves eyes as quickly as
possible from point to point. Perform 10 times. Record HDNF
on a zero to 10 scale.
D. Convergence
. Service member and provider are seated facing
each other. Service member focuses on font target (page 14)
at arm’s length and slowly brings toward tip of nose. Service
member stops target when two distinct images seen or when
outward deviation of eye observed. Repeat and measure three
times. Record centimeters between target and tip of nose for
each trial. A near point of convergence ≥ ve centimeters from
the tip of the nose is considered abnormal. Record HDNF on a
zero to 10 scale.
Consider defering VOMS if patient is overtly symptomatic or a
t
rained provider unavailable. VOMS should be completed before
return to duty. Use comment section for any provider-observed
difculty with specic VOMS tasks.
VOMS Contraindication: Unstable Cervical Spine.
17. Vestibular/Ocular-Motor Screening (VOMS) for
Concussion Instructions
Health.mil/TBICoE Page 11 of 14
MACE 2 - Military Acute Concussion Evaluation
Revised 03/2021
E. Vestibular-ocular reex (VOR) test
. Service member and
examiner are seated. Examiner holds font target (page 14) in
front of service member in midline at three feet, rotation speed
set with metronome.
1) H orizontal VOR test:
Service member rotates head
horizontally focusing on target at 20 degrees to each side.
Rotation = 180 beats per minute (bpm). Perform 10 times.
Record: HDNF 10 seconds after test.
2) Vertical VOR test:
Repeat test moving head vertically 20
degrees up and down at 180 bpm. Perform 10 times. Record
HDNF 10 seconds after test.
F. Visual motion sensitivity (VMS) test
. Service member stands
with feet shoulder width apart, facing a busy area. Examiner
stands next to and slightly behind service member. Service
member outstretches arm. Focusing on their thumb, the service
member rotates head,eyes and trunk as unit 80 degrees right
and left. Rotation = 50 bpm. Perform ve times. Record HDNF on
a zero to 10 scale.
17. Vestibular/Ocular-Motor Screening (VOMS) for
Concussion Instructions (Continued)
Health.mil/TBICoERevised 03/2021
Vestibular/Ocular
Motor Test :
Not
Tested
Headache
0-10
Dizziness
0-10
Nausea
0-10
Fogginess
0-10
Comments
BASELINE
SYMPTOMS:
N/A
Smooth Pursuits
Saccades –
Horizontal
Saccades –
Vertical
Convergence
(Near Point)
(Near Point in cm):
Measure 1: ______
Measure 2:______
Measure 3:______
VOR –
Horizontal
VOR – Vertical
Visual Motion
Sensitivity Test
Total
MACE 2 - Military Acute Concussion Evaluation
17. VOMS Score Card
Page 12 of 14
Any score above baseline is considered abnormal
VOMS RESULTS
All Normal
Any Abnormal
Health.mil/TBICoE Page 13 of 14Revised 03/2021
MACE 2 - Military Acute Concussion Evaluation
EXAM SUMMARY
Record the data for correct MACE 2 documentation.
NEUROLOGICAL RESULTS
(Q 7-14)
Abnormal (+)
Normal (-)
VOMS RESULTS
(Q 17)
Abnormal (+) Normal (-) Deferred
SYMPTOM RESULTS
(Q 3)
1 or more symptoms (+) No symptoms (-)
HISTORY RESULTS
(Q 4A-4C)
Positive (+)
Negative (-)
Cognitive Summary
Orientation Total Score - Q5
5
5
5
15
30
Concentration Total Score
(Sections A and B)
- Q15
Delayed Recall Total Score - Q16
Immediate Memory Total Score
(all 3 trials)
-
COGNITIVE RESULTS
≤ 25 is abnormal
AFTER COMPLETING MACE 2:
MACE 2 RESULTS
Positive (+)
Negative (-)
❏
Document MACE 2 results in the EHR with coding instructions.
❏
I nitiate the Progressive Return to Activity (PRA) Clinical
Recommendation beginning with Initial Concussion
Management to include 24-hours rest.
Refer to Progressive Return to Activity Clinical Recommendation at Health.mil/
TBIProviders
Health.mil/TBICoE Page 14 of 14
MACE 2 - Military Acute Concussion Evaluation
Revised 03/2021
THIS TOOL MAY BE COPIED FOR CLINICAL USE.
We are authorized to collect the information on this form and any
supporting documentation, including social security numbers, under the
Patient Protection and Affordable Care Act (Public Law No. 111-148), as
amended by the Health Care and Education Reconciliation Act of 2010
(Public Law No. 111-152), and the Social Security Act.
Centimeter Ruler
0 cm 5 cm
15 cm
Sample 14 point font:
A
VOMS Equipment
References available at Health.mil/TBIProviders.
TBI CODING INSTRUCTIONS
For more information, see TBICoE ICD-10 Coding Guidance Tool.
PUID 4901.1.3.8
Released: February 2012 | Revised March 2021
by Traumatic Brian Injury Center of Excellence.
This product is reviewed annually and is current until superseded.
If TBI screening is negative, code: Z13.850*
* MACE 2
** Etiology, Location, Severity, Encounter
*** D eployment code must fall within the rst four
codes when applicable
TBI coding sequence:
1. Primary TBI diagnostic code: S06. E L S E**
2. Primary symptom code, i
f applicable:
(e.g., H53.2 - diplopia)
3. Deployment status code, if applicable:***
(e.g., Z56.82 for deployed or Z91.82 for history
of military deployment)
4. TBI external cause of morbidity code: (For
example, Y36.290A (A- use for initial visit) for
war operations involving other explosions and
fragments, military personnel, initial encounter)
5. Place of occurrence code, if applicable
6. Activity code, if applicable
7. Personal History of TBI code: if applicable
Z87.820