Medical Questionnaire

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please read carefully and answer the following questions on your past or present medical history with a YES or NO. If you answer YES to any of the questions below we require a clearance in writing from a physician prior to participating in scuba diving. This doctors certificate needs to be printed out and give to shop staff minimum one day prior the course

Please fill in all required fields.

Name

Date of Birth

Hotel

Shoe Size

Height

Weight

Box A - I have/have had:

Could you be pregnant, or are you attempting to become pregnant?

Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)

Are you over 45 years of age? AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?

Frequent or severe attacks of hay fever or allergy?

Frequent colds, sinusitis or bronchitis?

Any form of lung disease?

Pneumothorax (collapsed lung)?

Other chest disease or chest surgery?

Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?

Epilepsy, seizures, convulsions or take medications to prevent them?

Recurring complicated migraine headaches or take medications to pre- vent them?

Blackouts or fainting (full/partial loss of consciousness)?

Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?

Dysentery or dehydration requiring medical intervention?

Any dive accidents or decompression sickness?

Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?

Head injury with loss of consciousness in the past five years?

Recurrent back problems?

Back or spinal surgery?

Diabetes?

Back, arm or leg problems following surgery, injury or fracture?

High blood pressure or take medicine to control blood pressure?

Heart disease?

Heart attack?

Angina, heart surgery or blood vessel surgery?

Sinus surgery?

Ear disease or surgery, hearing loss or problems with balance?

Recurrent ear problems?

Bleeding or other blood disorders?

Hernia?

Ulcers or ulcer surgery?

A colostomy or ileostomy?

Recreational drug use or treatment for, or alcoholism in the past five years?

I am over 10 years of age

I hereby acknowledge that I am not flying within 18 hours after the programs last dive

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