Medical Diagnostics Form For Athletes With Physical Impairment

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Medical Diagnostics Form
for athletes with physical impairment
The form is to be completed in English by the athlete’s individual physician.
The completed form must be uploaded to the athlete’s SDMS profile no later than six (6) weeks before
the athlete undergoes athlete evaluation. This applies to all athletes with physical impairment competing
in IPC Sports. Depending on the athlete’s health condition and impairment, additional medical
information is to be attached to this form (see page 2).
Athlete Information
Last name:
First name:
 Female
 Male
Date of Birth:
Years/months competing in the sport at national level:
Medical Information
Description of the Athlete’s medical diagnosis and the loss of function this health condition results in:
Health condition is:
 progressive  stable
Medical history:
Health condition is:
 acquired
 congenital
If acquired, age of onset:
Anticipated future procedure(s):
Medical Diagnostics Form for Athletes with Physical Impairment – Version September 2013


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