Date of Onset: __________________ Athlete’s Age at Onset: _____________________ Impairments Check the box/es below to indicate which impairment type/s the athlete has that lead/s to a permanent and verifiable activity limitation. Permanent and Verifiable Examples of health Additional supporting Impairment Type condition (diagnosis) likely tests/documentation that are to cause such impairment mandatory (*) or must be presented upon request Impaired Muscle Power Spinal cord injury, muscular Manual muscle test results* dystrophy, brachial plexus EMGs; nerve conduction injury, Erb’s palsy, polio, velocity spina bifida, Guillain-Barre syndrome Impaired Range of Arthrogryposis, ankylosis, Goniometric measurements*; Movement post burns, joint x-rays; contractures Limb deficiency Amputation resulting from Photograph of affected limb* trauma or congenital limb deficiency Hypertonia Cerebral palsy, stroke, brain Manual muscle test results. injury, multiple sclerosis Coordination testing. Ataxia Ataxia resulting from Manual muscle test results. cerebral brain injury, Coordination testing. Friedreich’s ataxia, multiple sclerosis, spinocerebellar ataxia Athetosis Cerebral palsy, stroke, brain Manual muscle test results. injury Coordination testing. Vision Impairment Myopia, tunnel vision, Complete IBSA medical scotoma, retinitis diagnostics form*. (see link at pigmentosa, glaucoma, www.worldrowing.com ) congenital cataract, macular degeneration
Date of Onset: __________________ Athlete’s Age at Onset: _____________________ Impairments Check the box/es below to indicate which impairment type/s the athlete has that lead/s to a permanent and verifiable activity limitation. Permanent and Verifiable Impairment Type Examples of health condition (diagnosis) likely to cause such impairment Additional supporting tests/documentation that are mandatory (*) or must be presented upon request Impaired Muscle Power Spinal cord injury, muscular dystrophy, brachial plexus injury, Erb’s palsy, polio, spina bifida, Guillain-Barre syndrome Manual muscle test results* EMGs; nerve conduction velocity Impaired Range of Movement Arthrogryposis, ankylosis, post burns, joint contractures Goniometric measurements*; x-rays; Limb deficiency Amputation resulting from trauma or congenital limb deficiency Photograph of affected limb* Hypertonia Cerebral palsy, stroke, brain injury, multiple sclerosis Manual muscle test results. Coordination testing. Ataxia Ataxia resulting from cerebral brain injury, Friedreich’s ataxia, multiple sclerosis, spinocerebellar ataxia Manual muscle test results. Coordination testing. Athetosis Cerebral palsy, stroke, brain injury Manual muscle test results. Coordination testing. Vision Impairment Myopia, tunnel vision, scotoma, retinitis pigmentosa, glaucoma, congenital cataract, macular degeneration Complete IBSA medical diagnostics form*. (see link at www.worldrowing.com )