MEDICAL DIAGNOSTICS FORM FOR ATHLETESWITH VISUAL IMPAIRMENTTHE FORM IS TO BE COMPLETED IN ENGLISH BY A REGISTERED OPHTHALMOLOGIST.
All medical documentation required in Section 4. 0must 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 Applications will be returned and will need to be re-submitted.
Athletes cannot receive a valid Licence until this Medical Form is properly completed and submitted.

1.

ATHLETE INFORMATION

Last Name:____________________________________________________________________First Name:____________________________________________________________________

Gender:Female q

NPC/NF:___________________________________________

Sport:_____________________________________________________________________________________

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Maleq

Date of Birth(dd/mm/yyyy):_________________________Country:_________________________

2.

MEDICAL INFORMATION FOR VISUAL IMPAIRMENT

The form and the attached medical documentation may not be older than 12 months at the time of the Athlete Evaluation.
2.1. DIAGNOSIS: Description of the Athlete’s medical diagnosis and the loss of function this health condition results in:

HEALTH CONDITION IS:

q FLUCTUATINGq STABLE

2.2. MEDICAL HISTORY FOR VISUAL IMPAIRMENTAge of onset:___________________________________________

Anticipated future procedure(s):___________________________________________

Athlete wears glasses:

Yes q

No q

Correction:

Right: ________________________
Left: _________________________

Athlete wears contact lenses:

Yes qAthlete wears eye prosthesis:

Right qNo q

Correction:

Right: ________________________
Left: _________________________Left q2.3. MEDICATIONS
Eye medications used by the athlete:
Ocular drug allergies:

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3.

ASSESSMENT OF VISUAL ACUITY AND VISUAL FIELD

3.1. VISUAL ACUITY
Visual acuity must be measured in LogMAR scale.
RIGHT EYE

LEFT EYE

With Correction

Without Correction

Type of correction:_________________________________________________________________________

Measurement Method:_________________________________________________________________________

3.2. VISUAL FIELDRIGHT EYE
In degrees (radius)

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LEFT EYE

4.

ATTACHMENTS TO THE MEDICAL DIAGNOSTICS FORM

4.1. 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 30 degrees, 24 degrees or 10 degrees central fieldtest, 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).
4.2. ADDITIONAL MEDICAL DOCUMENTATION
Please specify which eye condition the athlete is affected by.
EYE CONDITION
ADDITIONAL MEDICAL DOCUMENTATION REQUIRED (SEE BELOW)
q Anterior diseaseNone

q Macular disease••••Macular OCTMultifocal and/or pattern ERG*
VEP*
Pattern appearance VEP*q Peripheral retina disease••

Full field ERG*
Pattern ERG*q Optic Nerve disease

••
•
•

OCT
Pattern ERG*
Pattern VEP*
Pattern appearance VEP

q Cortical / Neurological disease•••

Pattern VEP*
Pattern ERG*
Pattern appearance VEP*

The ocular signs must correspond to the diagnosis and degree of vision loss. If eye condition is obvious and visible andexplains the loss of vision, no additional medical documentation is required. Otherwise, the additional medical
documentation indicated in the above table must be attached to this form. If the medical documentation is incomplete, theclassifiers will not be able to allocate a sport 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 oculardisease the use of visual electrophysiology is often helpful in demonstrating the degree of 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, and its calibration status. The tests should be
performed as a minimum to the standards laid down by the International Society for Electrophysiology 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 of light 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 originating in the retinal
ganglion cells.
• A Multifocal ERG tests the central area (approx. 50 degrees diameter) and produces a topographical representation ofcentral retinal activity.
A Visual evoked cortical potential (VEP) records the signal from produced in the primary visual cortex, (V1), in response to eithera pattern stimulus or pulse of light. An absent or abnormal VEP is not in itself evidence of 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 toobjectively demonstrate visual ability to the level of the primary visual cortex.
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5.

OPHTHALMOLOGIST DECLARATIONq

I certify that the above-mentioned information is medically appropriate.

q

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 Ophthalmologist:

Date:_____________________________

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