Medical Diagnostics Form For Athlets With Physical Impairment Page 2
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2Athlete's last name:
Athlete's SDMS ID:
Medication:
Attachments
The athlete’s health condition as stated on this form and the resulting impairment must fully explain the
loss of function exhibited by the athlete during athlete evaluation. Otherwise no sport class can be
allocated by the classification panel, as stipulated in the IPC Sport’s classification rules.
Therefore, additional, recent and relevant medical documentation has to be attached to this form if the
athlete has*
an impairment or diagnosis that cannot be ascertained by clear signs and symptoms;
a complex or rare health condition, or multiple impairments;
limb deficiency (amputation or dysmelia) at the level of an ankle, knee, wrist or elbow joint (X-
rays for the respective joints to be enclosed);
a spinal cord injury (recent ASIA scale results to be enclosed);
one of the coordination related impairments ataxia, athetosis or hypertonia (Modified Ashworth
Scale scores to be enclosed).
Reports on additional testing by physicians, physiotherapists and other health professionals are
welcomed, where relevant, to complement the medical diagnostic information.
The IPC Sport and the Classification Panel may ask for further information to be submitted depending on
the individual athlete’s health condition and impairment.
*Athletes and NPCs/ NFs are advised to observe the Eligible Impairments defined in each IPC Sport’s
classification rules, as not all of the impairments mentioned above are considered Eligible Impairments in
all sports.
I confirm that the above information is accurate.
Name:
Health care profession:
Registration Authority and Number:
Address:
City:
Country:
Phone:
E-mail:
Date:
Signature:
Medical Diagnostics Form for Athletes with Physical Impairment – Version September 2013
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