Diving Check-in

MEDICAL STATEMENT PARTICIPANT RECORD

Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving ftness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

DIRECTIONS

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.

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 and/or blood affecting my normal physical or mental performance.

Yes

No

I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease

Yes

No

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

Yes

No

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.

Yes

No

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

Yes

No

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

Yes

No

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2. I am over 45 years of age.

Yes

No

I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.

Yes

No

I have a high cholesterol level.

Yes

No

I have high blood pressure.

Yes

No

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).

Yes

No

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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 ftness or health reasons within the past 12 months.

Yes

No

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

Yes

No

I have/have had:

Sinus surgery within the last 6 months.

Yes

No

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

Yes

No

Recurrent sinusitis within the past 12 months

Yes

No

Eye surgery within the past 3 months.

Yes

No

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

Yes

No

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

Yes

No

I have/have had:

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

Yes

No

Persistent neurologic injury or disease.

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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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 or developmental disability

Yes

No

I have/have had:

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

I have/have had:

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

Yes

No

Back or spinal surgery within the last 12 months.

Yes

No

Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.

Yes

No

An uncorrected hernia that limits my physical abilities.

Yes

No

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

Yes

No

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

Yes

No

I have/have had:

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

Yes

No

Dehydration requiring medical intervention within the last 7 days.

Yes

No

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

Yes

No

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

Yes

No

Active or uncontrolled ulcerative colitis or Crohn’s disease.

Yes

No

Bariatric surgery within the last 12 months.

Yes

No

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

Yes

No

PARTICIPANT SIGNATURE

If you answered NOto 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 YESto questions 3, 5 or 10 aboveOrto any of the questions on page 2, please read and agree to the statement above by signing and dating itAND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physicianfor a medical evaluation. Participation in a diving course requires your physician’s approval.

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Participant's Signature

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