Physician AAI Form for Virtus Sport

Physician AAI Clearance Form

For athletes with Down Syndrome applying for Virtus or Paralympic Sport Eligibility
Greetings supporting Physicians!

Your patient is a high-performance athlete who requires this Atlantoaxial Instability Clearance Form as part of their Virtus & Paralympic sport eligibility application.

This form has been built in a hipaa-compliant environment to protect privacy. A simple confirmation email (without medical information) will be sent to the athlete's email address just so they know it's been completed.

Athletes Without Limits is a 501(c) nonprofit that has been helping athletes with Intellectual Impairments access opportunites to compete at their highest level in sport since 2009! If you have any questions please CONTACT US and we're happy to help!

Learn more at athleteswithoutlimits.org.
A past or new AAI Neck Xray Report is required to complete this form. Which does the athlete have?*

Athlete has not had a neck x-rayA new neck scan report is being reviewed and providedA previous neck scan report is being reviewed and providedDate of Report
NECK X-RAY IS NEEDED
For safety reasons if the athlete has not had a neck x-ray one will need to be scheduled before this form can be completed — the answers must be based on a scan review.
UPLOAD COPY OF PREVIOUS OR NEW NECK X-RAY REPORT*

Cancelof
PART 1: ATHLETE INFORMATION

All questions below should be completed by a qualified medical practitioner.
Athletes Name in One Field (hidden)
Athlete/Patient Name

First NameLast Name
Athlete/Patient Email (for confirmation that form was submitted)
No medical information will be included in email confirmation to protect privacy.
1. Does the athlete have a known diagnosis of symptomatic AAI?*

NoYes
2. Does the athlete show evidence of progressive Myopathy?*

NoYes
3. Does the athlete patient have poor head/neck muscular control?*

NoYes
4. Does the athlete patient's neck flexion allow the chin to rest on their chest?*

NoYes
5. Please confirm the type of Down syndrome the athlete has:*

Not SureTrisomy 21TranslocationMosaic
PART 2: PHYSICIAN INFORMATION & SIGNATURE
Physician Name*
Physician Credentials/Specialty*
Physician Clinic or Practice Name
Physician Address*
Physician Phone Number*
Please enter a valid phone number.
Physician Email Address (for confirmation that form was submitted)*
No medical information will be included in email confirmation to protect privacy.
Physician Statements:*

In my professional opinion I confirm the athlete is free from symptomatic AAI and is safe to participate in competitive sport.I confirm the athlete and their family/guardians have been made aware of the risk and that Virtus: World Intellectual Impairment Sport and its USA Member Athletes Without Limits accepts no responsibility in the event of injury arising from AAI.I confirm that I am a physician/doctor qualified in assessment and diagnosis of AAI.
Physician Signature*

Clear
Physician Date Signed

MonthDayYear
Date
AAI Status:
Should be Empty:

Physician AAI Clearance Form

PART 1: ATHLETE INFORMATION

PART 2: PHYSICIAN INFORMATION & SIGNATURE