Forms - Diver Medical Questionnaire

The Dive Centre this applies to:

Full Name

Date of Birth

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

1. I have had problems with my lungs/breathing, heart, blood affecting my normal physical or mental performance.
YesNo

Box A– I have/have had:
Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax and/or chronic lung disease.
YesNo

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
YesNo

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
YesNo

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
YesNo

Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.
YesNo

2. I am over 45 years of age.
YesNo

Box B– I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
YesNo

I have a high cholesterol level.
YesNo

I have high blood pressure.
YesNo

I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
YesNo

3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.
YesNo

4. I have had problems with my eyes, ears, or nasal passages/sinuses.
YesNo

Box C– I have/have had:

Sinus surgery within the last 6 months.
YesNo

Ear disease or ear surgery, hearing loss, or problems with balance.
YesNo

Recurrent sinusitis within the past 12 months.
YesNo

Eye surgery within the past 3 months.
YesNo

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery
YesNo

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
YesNo

Box D– I have/have had:

Head injury with loss of consciousness within the past 5 years.
YesNo

Persistent neurologic injury or disease.
YesNo

Recurring migraine headaches within the past 12 months, or take medications to prevent them.
YesNo

Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
YesNo

Epilepsy, seizures, or convulsions, OR take medications to prevent them.
YesNo

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.
YesNo

Box E– I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
YesNo

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
YesNo

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.
YesNo

An addiction to drugs or alcohol requiring treatment within the last 5 years.
YesNo

8. I have had back problems, hernia, ulcers, or diabetes.
YesNo

Box F– I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
YesNo

Back or spinal surgery within the last 12 months.
YesNo

Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
YesNo

An uncorrected hernia that limits my physical abilities.
YesNo

Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
YesNo

9. I have had stomach or intestine problems, including recent diarrhea
YesNo

Box G– I have/have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
YesNo

Dehydration requiring medical intervention within the last 7 days.
YesNo

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
YesNo

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
YesNo

Active or uncontrolled ulcerative colitis or Crohn’s disease.
YesNo

Bariatric surgery within the last 12 months.
YesNo

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).
YesNo

Participant Signature

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

Participant Statement

I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

If you answered YES to questions 3, 5 or 10 above OR to any of the questions in the extra boxes, please read and agree to the statement above by signing and dating it. You can download a paper copy of this form and a medical, which you MUST COMPLETE and take ALL THREE pages (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course in this circumstance requires your physician’s approval.

Please, draw your Signature (or, if a minor, participant‘s parent/guardian signature required)

Date of Signing

I accept and understand that Jenny Lord will collect the answers of this medical statement in order to check that I can safely participate in scuba diving activities.

Forms – Diver Medical Questionnaire

Participant Signature

Participant Statement