Medical Diagnostics Form For Athletes With Visual Impairment Page 2
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4Athlete:
Assessment of visual acuity and visual field
Visual Acuity
Right eye
Left eye
With correction
Without Correction
Type of correction:
Measurement Method:
Visual Field:
In degrees (radius)
Right eye
Left eye
Attachments to the Medical Diagnostic Form
1. Visual field test
For all athletes with a restricted visual field a visual field test must be attached to this form.
The athlete’s visual field must be tested by full-field test (120 degrees) and a 30 degrees, 24 degrees or 10
degrees central field test, depending on the pathology.
One of the following perimeters should be used for the assessment: Goldmann Perimetry (Intensity III/4),
Humphrey Field Analyzer or Octopus (Interzeag).
2. Additional medical documentation
Please specify which eye condition the athlete is affected by.
Eye condition
Additional medical documentation required
(see below)
Anterior disease
none
Macular OCT
Multifocal and/or pattern ERG*
Macular disease
VEP*
Pattern appearance VEP*
Full field ERG*
Peripheral retina disease
Pattern ERG*
OCT
Pattern ERG*
Optic Nerve disease
Pattern VEP*
Pattern appearance VEP*
Pattern VEP*
Cortical / Neurological
Pattern ERG*
disease
Pattern appearance VEP*
Medical Diagnostics Form - Version June 2013
Page 2 of 4
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