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MEDICAL DIAGNOSTICS FORM FOR ATHLETES WITH VISUAL IMPAIRMENT

- This form must be completed by every individual athlete with visual impairment and pages 1-3 submitted to the respective International Federation (IF, see page 5) before classification.
- The form is to be filled out by a registered ophthalmologist (as applicable by country).
- The form is used to determine the athlete’ssight in accordance with the respective IF classification rules (eligibility criteria listed on page 4 as a reference).

PLEASE FILL OUT THIS FORM IN CAPITAL LETTERS OR TYPING

Incomplete Applications will be returned and will need to be resubmitted. Athletes cannot present for classification until applications have been completed.

1. ATHLETE INFORMATION

Surname:.Raul....................................... . Given Names: Alcantara .........................

Female ( Male ( Date of Birth (d/m/y): 12 08 1967…………

Address: Norte 92 5120 col. Getrudis Sanchez...............................................................

City: ......Mexico.......................................... Country: D.F................................

Sport:.Natacion..................................................................................................
















2. MEDICAL INFORMATION

Current diagnosis with sufficient medical information (see note 1)
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Medical history
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Age of onset: ………...
Anticipated future procedure(s):………………………....................
Glasses : YES / NO Contact Lenses: YES / NO Prosthesis: YES / NO

Correction: R:……….L:………. R: ……….L:……….……. LEFT / RIGHT

Eye Medications
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Eventual Drug Allergies:………………………………………………………………………….
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3. ASSESSMENT RESULTSVisual Acuity
| |With Correction |Without Correction |
|RE | | |
|LE | ||



Type of correction: ……………………………………………………………………….

Measurement Method: …………………………………………………………………..

Visual Field (see note 2) Please attach visual field map
| | | |Degrees (diameter) |
|RE | |LE| |


4. MEDICAL PRACTITIONER DECLARATION

( 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 speciality: .……………………………………………………………………………….

Registration number: ……………………………………………………………………………

Address: ……..…………………………………………………………………………………………………………..…………………………………………………………………………………………

Tel.: ……………………………………………E-mail: ………………………………………….


Signature of Medical Practitioner:...