ＭＤＦ（Medical Diagnostics Form）作成の手引き
2017/8/2

ＪＰＡクラス分け委員会作成

2017 年シーズンから、国際クラス分けを受ける必要がある選手については、World Para Athletics に登録する際に「Medical Diagnostics Form（以下、MDF）」を添付することが義務つけられました。
下記にしたがって、作成をお願いします。

＜MDF の提出が必要な選手＞
国際クラスステータスが以下に該当する者
１）New：N
２）Review : R３）Fixed Review Data〇〇〇〇（西暦） : FRD〇〇〇〇※登録年度と同じ数字が割り当てられている者に限る。FRD2017 のものは MDF が必ず必要

４）クラス分けマニュアルの変更等に伴いステータス R に変更となった者＜注意事項＞〇MDF は、Para Athletics に参加する資格を有しているかを証明する重要な書類の一つです。かかりつけ医もしくは、専門医に相談の上、必要な検査を実施したうえで作成をお願いします。
〇MDF（原本）に加え、次ページ以降に掲載してあります「肢体用」または「視覚用」の記載例を印刷し担当医にお渡しすることをお勧めします。
〇MDF の記載内容とご自身の障がい状況や国際クラス分け時の問診に対する返答などに齟齬が生じると「正確なクラス分けが実施できない」という事でクラス分けが中止になる恐れがあります。したがって、MDF の記載内容については作成医師より説明を受けご自身も十分ご理解ください。
〇障がいの原因となっている部位を証明するための医学的資料（レントゲンやCT、MRI 等）も MDF と共にご提出ください。
〇通常、診断書の作成のためには数日から 4 週間程度の時間（病院によって異なる）が必要となりますので、余裕をもってご準備ください。
〇かかりつけ医や近隣の医療機関での MDF の作成が困難である場合や、何か不明な点がある場合などは、JPA 事務局までご相談ください。

＜MDF の書式の入手方法＞
World Para Athletics ホームページ内の＜Classification＞－＜RULES & REGULATIONS>タグ内
VI Medical Diagnostics Form：視覚障がい用PI Medical Diagnostics Form：肢体障がい用
URL：https://www.paralympic.org/athletics/classification/rules-and-regulations

肢体障がい用MDF作成の手引き
Medical Diagnostics Formfor athletes with physical impairment
The form must be completed in English by a registered medical doctor (M.D.) with a
specialization in the appropriate medical field dealing with the Athlete’s Health Condition.
The completed form with attached medical documentation must be uploaded to the athlete’sSDMS profile upon registration of the athlete to the SDMS. This applies for all athletes withphysical impairment competing in [Para Sport]. Depending on the athlete’s health condition
and impairment, additional medical information is to be attached to this form (see page 2).
Note
The measurement of impairment seen during athlete evaluation must correspond to thediagnosis indicated below. If the medical documentation is incomplete, [Para Sport] holds theright to request further information. In absence of such information, the athlete will not be able
to proceed with Athlete Evaluation.
Athlete Information(to be prepopulated by the NPC)

※すべて英語で記入してください

姓
Family name:
名
Given name:
Gender: 性別
NPC: Female 女性  Male 男性

ＪＡＰＡＮ国名 The athlete’s Sport Class Status is New

Date of Birth:

生年月日日/月/西暦の順で記入 dd/mm/yyyy)

SDMS ID:
 The athlete’s Sport Class Status is Review

現在のクラスステータスを選択してください。
Ｎｅｗ：過去、国際クラス分けを受けた事がない選手。クラスステータスがＮｅｗである選手
Ｒｅｖｉｅｗ：過去、国際クラス分けを受けた事がある。クラスステータスがＲｅｖｉｅｗである選手※選手自身にご確認いただくか、不明な場合はJPA事務局までお問い合わせ下さい。

International Paralympic Committee
Adenauerallee 212-214
53113 Bonn, Germany

Tel. +49 228 2097-200
Fax +49 228 2097-209

www.paralympic.org
info@paralympic.org

対象者の機能障害について該当する項目に✔をご記入ください。また、この書類に添付する機能障害を証明する医学的資料に✔をご記入の上、該当資料を対象者にお渡しください。
※最近の傾向として、医学的資料の不足によりクラス分けが実施されないケースが生じています。
可能な限り医学的資料をご準備いただきますようお願いいたします。

Medical Information
Note: The list of medical diagnoses shows examples and is not exhaustive.
Eligible Impairment
Name medical diagnosis relevant to Documents to support the(tick)
impairment type (tick or add)
diagnosis (tick or add)
□ Impaired muscle□ Spinal Cord Injury□ Medical Reportpower□ Muscular Dystrophy□ ASIA scale□ Spina Bifida□ Electromyography□ Polio Myelitis□ MRI□ Multiple sclerosis□ X-rays□ Other_______________________ □ Biopsy_____________________________ □ Other_________________□ Impaired passive□ Arthrogryposis□ Medical Report
range of motion□ Joint Contractures□ X-rays□ Trauma□ Photographs□ Other______________________□ Goniometric measures of____________________________ joint limitations□ Ataxia□ Cerebral Palsy□ Medical Report□ Traumatic brain injury□ Modified Ashworth Scale□ Athetosis□ Multiple Sclerosis□ Cerebral MRI or TC scan
□ Hypertonia□ Stroke□ Other_________________□ Other____________________________________________________□ Leg length□ Trauma□ Medical Report
difference□ Dysmelia□ X-rays□ Other_______________________ □ Photograph_____________________________ □ Other_________________□ Short stature□ Achondroplasia□ Medical Report□ Osteogenesis Imperfecta□ X-rays□ Growth Hormone Dysfunction□ Photograph□ Other_______________________ □ Other______________________________________________□ Limb deficiency□ Dysmelia□ Medical Report□ Traumatic Amputation□ X-rays□ Bone Cancer□ Photographs□ Other_______________________ □ Other______________________________________________

Medical Diagnostics Form for Athletes with Physical Impairment – Version May 20172

Medical history:

安定的進行性

変動的永続的Athlete’s condition is:□ Stable□ Progressive□ Fluctuating□ Permanent

Age of onset:

発症日・受傷日（西暦で記入）(yyyy)Past treatments:

これまでの治療内容
これまでに行なわれた手術や治療経過についてご記入ください

Current treatments:

現在の治療内容
現在の治療内容についてご記入ください

Anticipated futuretreatments:

今後の治療予測
今後行われる手術や治療内容についてご記入ください□ Congenital 先天性

Additional details on medical diagnosis (if needed):
医学的診断の詳細（必要時）：
Medical Informationで選択した障がい種類の詳細な状況や複数の障がい種類を持っている場合、複雑な障がい状況を呈している場合などに詳細状況についてご記入ください。

Medications and reason for prescription:
薬剤と処方理由：

上記情報が間違いないものであることを保証される場合、下の□にチェックをお入れください I confirm that the above information is accurate.
Name:
Medical Specialty: 診療科目：
Registration Number: 登録番号：
Address:
City:

Country:

Phone: +81に続き局番の先頭０を省いたJAPANE-mail:

電話番号をご記入ください

Date: 日／月／西暦 でご記入ください Signature: 直筆でのご署名をお願いします

Medical Diagnostics Form for Athletes with Physical Impairment – Version May 20173

視覚障がい用ＭＤＦ記載例

Medical Diagnostics Formfor athletes with visual impairment

The form is to be completed in English and by a registered ophthalmologist.
All medical documentation required on pages 2-3 needs to be attached.
The form and the attached medical documentation may not be older than 12 months at the time of
the Athlete Evaluation.
Athlete Information
Last name:KokurihaFirst name:TaroGender:Female Male ✔

Date of Birth:Sport: 競技名 Track, Field, Swimming, Goalball etc.
NPC/NF:IF registration ID(if applicable):

JAPAN

Medical Information
Diagnosis:）Retinitis Pigmentosa
Leber hereditary optic neuropathy
Glaucoma
Diabetic Retinopathy
Retinopathy of prematurity
Microphthlmos

Medical history:
Age of onset:
Anticipated future
procedure(s):Athlete wears
glasses:
Athlete wears
contact lenses:
Athlete wears eye
prosthesis:

01/Jan/1900

空欄で可Persistent hyperplastic primary vitreous(PHPV)
Albinism
Macular hypoplasiaなど疾患名を記載

発症が不詳でも何歳と確認して記載する。極力unknownは避ける。

20years old, CongenitalPoor✔ yes noCorrection:

Right:

 yes
✔ noCorrection:

Right:
Left:

使用していれば度数を記載 Left: right  left

Medication:
Eye medications
None or 使用中の薬剤名を英語表記
used by the athlete:
Ocular drug allergies:

None or 眼科関連薬剤でアレルギーがあれば薬剤名を英語表記

Athlete:

JAPANKokuriha

Assessment of visual acuity and visual field
Visual Acuity
Right eyeWith correction

Left eyeWithout Correction
Type of correction:
Measurement Method:

ランドル環での視力測定で問題無い

Visual Field: GPではⅢ/４eの測定が必要
In degrees (radius)
Right eye（別紙で添付）

Left eye（別紙で添付）

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 10degrees 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
 Anterior disease Macular disease✔ Peripheral retina disease Optic Nerve disease Cortical / Neurologicaldisease

Additional medical documentation required (see below)none


Macular OCT
Multifocal and/or pattern ERG*
VEP*
Pattern appearance VEP*
Full field ERG*
Pattern ERG*
OCT
Pattern ERG*
Pattern VEP*
Pattern appearance VEP*
Pattern VEP*
Pattern ERG*
Pattern appearance VEP*

Medical Diagnostics Form - Version June 2013

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Athlete:

JAPANKokurihaThe ocular signs must correspond to the diagnosis and degree of vision loss. If eye condition isobvious and visible and explains the loss of vision, no additional medical documentation is required.
Otherwise the additional medical documentation indicated in the above table must be attached tothis form. If the medical documentation is incomplete, the classifiers will not be able to allocate asport class.
*Notes on electrophysiological assessments (VEPs and ERGs):
Where there is discrepancy or a possible discrepancy between the degree of visual loss, and the visible
evidence of ocular disease the use of visual electrophysiology is often helpful in demonstrating the degreeof impairment.
Submitted data should include the report from the laboratory performing the tests, copies of the original
data, the normative data range for that laboratory, and a statement specifying of the equipment used, andits calibration status. The tests should be performed as a minimum to the standards laid down by theInternational Society for Electrophysiolgy of Vision (ISCEV) (http://www.iscev.org/standards/).
A Full Field Electroretinogram (ERG) tests the function of the whole retina in response to brief flashes oflight, and can separate function from either the rod or cone mediated systems. It does not however give
any indication of macular function.
 A Pattern ERG tests the central retinal function, driven by the macular cones but largely originatingin the retinal ganglion cells.
 A Multifocal ERG tests the central area (approx. 50 degrees diameter) and produces a
topographical representation of central retinal activity.
A Visual evoked cortical potential (VEP) records the signal from produced in the primary visual cortex, (V1),in response to either a pattern stimulus or pulse of light. An absent or abnormal VEP is not in itself evidenceof specific optic nerve or visual cortex problems unless normal central retinal function has been
demonstrated.
 A Pattern appearance VEP is specialised version of the VEP used to establish visual threshold
which can be used to objectively demonstrate visual ability to the level of the primary visual cortex.
I confirm that the above information is accurate.
I certify that there is no contra-indication for this athlete to compete at competitive level insport, with the exception of _________________________________________________.
Name:Taro Kokuriha✔
✔

Medical Specialty:
Registration Number: No. 000000 (Japanese medical doctor's registration number)
Address:（職場の住所）

City:
Phone:
Date:

市外局番の先頭の0を省く
01/Jun/2016

Medical Diagnostics Form - Version June 2013

Country:
E-mail:Signature:JAPAN

使用中のアドレス（職場メール可）
署名は日本語で問題無い

Page 3 of 4

Athlete: JAPANKokurihaThis Medical Diagnostic Form with attachments is to be submitted to the respective IF:IF/ SportIPC Sports Alpine Skiing,
Athletics,
Nordic Skiing,
Swimming
IBSA – Football
5-a-side,
Goalball, JudoUCI - Cycling

FEI - Equestrian

FISA - Rowing

IFDS - Sailing

ITU - Triathlon

Address
International Paralympic Committee
Adenauerallee 212-214
53113 Bonn
Germany

To be submitted to:Upload to athlete’s profile in the SDMS
database at least four weeks before thecompetition

IBSA
Attn. Neil O’Donovan
IBSA Executive Director
115 George’s Street Lower,
Dunleary, Co. Dublin
IrelandUCI – Para-Cycling
UCI Headquarters
Chemin de la Mêlée 121860 Aigle
SwitzerlandFédération Equestre Internationale
HM King Hussein I Building
Chemin de la Joliette 81006 Lausanne
Switzerland
FISA
Attn. FISA Head of Classification
Maison du Sport International
Av. de Rhodanie 54
1007 Lausanne
Switzerland
IFDS
Ariadne House
Town Quay
Southampton, Hampshire
SO14 2AQ
United Kingdom
International Triathlon Union (ITU)#221, 998 Harbourside Dr. North
Vancouver, BC,Canada, V7P 3T2

E-mail: exd@ibsa-sports.org

Medical Diagnostics Form - Version June 2013

Fax +41-24-468-5812
E-mail: christophe.cheseaux@uci.ch

Fax +41 21 310 4760
E-mail: trond.asmyr@fei.org

Fax +41 21 617 8375
E-mail: info@fisa.org with attn. FISA Headof Classification

Fax. +44 23 8063 5789
E-mail: ifds@isaf.co.uk

E-mail: eric.angstadt@triathlon.org

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