MEDICAL DIAGNOSTICS FORM FOR ATHLETESWITH PHYSICAL IMPAIRMENTTHE MEDICAL DIAGNOTICS FORM (MDF) IS TO BE COMPLETED IN ENGLISH BY THE ATHLETE’S PHYSICIAN.
All medical documentation required in Section 4. must be attached at the end of this form and uploaded on the IFSC results
system together with the Licence request.
Please fill out the form legibly and in capital letters.
Incomplete MDFs will be rejected and will need to be re-submitted. Athletes cannot receive a valid Annual Licence until thisMDF is properly completed and submitted.
1.

ATHLETE INFORMATION

Last Name:____________________________________________________________________First Name:____________________________________________________________________

Gender:Female q

NPC/NF:___________________________________________

Sport:_____________________________________________________________________________________

2.

Maleq

Date of Birth(dd/mm/yyyy):_________________________Country:_________________________ELIGIBLE IMPAIRMENT TYPE

Please select all the Eligible Impairment type(s) applying to the Athlete. Refer to the IFSC Classification Rules for full details.
q 1. Impaired Muscle Powerq 4. Leg Length Difference

q 7. Ataxia

q 2. Impaired Passive Range of Movement

q 5. Short Stature (height: ______ cm)

q 8. Athetosis

q 3. Limb Deficiency

q 6. Hypertonia

Physical Impairments other than the eight (8) Eligible Impairment types listed above are considered Non Eligible Impairments.

Page 1 – IFSC Medical Diagnostics Form PI

3.

MEDICAL INFORMATION

3.1. DIAGNOSIS: Description of the Athlete’s medical diagnosis and the loss of function this health condition results in:

HEALTH CONDITION IS:

q FLUCTUATINGq STABLE

q PERMANENTq PROGRESSIVE

3.2. MEDICAL HISTORYIMPAIRMENT IS:

q ACQUIREDIf acquired, year of onset:_________________________________________________________

Anticipated future procedure(s):______________________________________________________________

3.3. MEDICATIONSPage 2 – IFSC Medical Diagnostics Form PI

q CONGENITAL

4.

ATTACHMENTS TO THE MEDICAL DIAGNOSTICS FORM

The athlete’s diagnosis/health condition as stated in this form must fully explain the loss of function/resulting impairment exhibited by the athlete during athlete evaluation. Otherwise, no Sport Class can be allocated by the Classification Panel, as stipulated
in the IFSC Classification Rules.
•Additional medical documentation in English language and no older than 12 months must be attached to this form if
the athlete has:

IMPAIRMENT
An impairment or diagnosis that cannot be ascertained byclear signs and symptoms.
A complex or rare health condition, or multiple impairments.
Limb deficiency (amputation or dysmelia) at the level of ankle,
knee, wrist, or elbow joint.
A spinal cord injury.
An impairment to spine ROM
An impairment resulting in ataxia
An impairment resulting in athetosis
One of the impairments resulting in hypertonicity (Dystoniaand Spasticity)

DOCUMENTS NEEDEDLetter from athlete’s physician describing these impairments
in enough detail to ascertain eligibility to compete.
Letter from athlete’s physician describing these impairments
in enough detail to ascertain eligibility to compete.
Recent X-ray or picture for each affected limb.
Report of the hospital/rehab centre after the accident and rehab and recent ASIA scale results
Recent spine X-ray
Letter from athlete’s physician describing the effect of theimpairment on athlete’s function.
Letter from athlete’s physician describing the effect of theimpairment on athlete’s function.
Modified Ashworth scores or Australian Spasticity Assessment
Scores for the relevant muscle group/s.

IMPORTANT
If it is not possible to provide the above-mentioned documentation associated with the impairment described, please enclose
a letter from a medical doctor including information sufficient to replace the assessment requested.
Reports on additional testing by physicians, physiotherapists and other health professionals are welcome, where relevant, tocomplement the medical diagnostic information.
The IFSC and the Classification Panel may ask for further information to be submitted depending on the individual athlete’s healthcondition and impairment.
5.

PHYSICIAN DECLARATIONqq

I certify that the above-mentioned information is medically appropriate.
I certify that there is no contra-indication for this individual to compete at competitive level in the sport mentioned.

Name:____________________________________________________________________________

Medical Specialty:____________________________________________________________________________

Registration Number:____________________________________________________________________________

Address:____________________________________________________________________________

City:______________________________Country:_____________________________

Tel.:_____________________________

E-mail:_____________________________

Signature of Physician:Date:_____________________________

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