Medical Diagnostics Formfor athletes with physical impairment
The form must be completed in English by a registered medical doctor (M.D.) with aspecialization 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’s
SDMS 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)

Family name:
Given name:
Gender: Female MaleNPC:

Date of Birth:(dd/mm/yyyy)

SDMS ID:

 The athlete’s Sport Class Status is New

 The athlete’s Sport Class Status is Review

International Paralympic CommitteeAdenauerallee 212-214
53113 Bonn, Germany

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

www.paralympic.org
info@paralympic.org

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:
Athlete’s condition is:□ Stable□ Progressive

Age of onset:□ Fluctuating(yyyy)□ Permanent□ Congenital

Past treatments:
Current treatments:
Anticipated futuretreatments:
Additional details on medical diagnosis (if needed):

Medications and reason for prescription:

 I confirm that the above information is accurate.
Name:
Medical Specialty:
Registration Number:
Address:
City:

Country:

Phone:

E-mail:Date:

Signature:

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