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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 fitness 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. If any of the answer is YES, then please answer the revelant questions in boxes that appear in the second page

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.

q1*

Yes

If "Yes"
Go to box A

2: I am over 45 years of age.

q2*

Yes

If "Yes" Go to box B

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.

q3*

Yes

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

q4*

Yes

If "Yes" Go to box C

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

q5*

Yes

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

q6*

Yes

If "Yes" Go to box D

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.

q7*

Yes

If "Yes" Go to box E

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

q8*

Yes

If "Yes" Go to box F

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

q9*

Yes

If "Yes" Go to box G

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

q10*

Yes

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.

Participant Signature*

(or, if a minor, participant‘s parent/guardian signature required.

Date*

MM slash DD slash YYYY

Participant Name*

Date*

MM slash DD slash YYYY

Instructor Name

Facility Name

Gulf Divers LLC

Facility Name

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

Participant Name*

Date*

MM slash DD slash YYYY

Diver Medical | Participant Questionnaire Continued

Download Medical Evaluation Form

BOX A – 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.

q11

Yes

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

q12

Yes

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.

q13

Yes

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

q14

Yes

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

q15

Yes

BOX B – I AM OVER 45 YEARS OF AGE AND:

I currently smoke or inhale nicotine by other means.

q16

Yes

I have a high cholesterol level.

q17

Yes

I have high blood pressure.

q18

Yes

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).

q19

Yes

BOX C – I HAVE/HAVE HAD:

Sinus surgery within the last 6 months.

q20

Yes

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

q21

Yes

Recurrent sinusitis within the past 12 months.

q22

Yes

Eye surgery within the past 3 months.

q23

Yes

BOX D – I HAVE/HAVE HAD:

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

q24

Yes

Persistent neurologic injury or disease.

q25

Yes

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

q26

Yes

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

q27

Yes

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

q28

Yes

BOX E – I HAVE/HAVE HAD:

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

q29

Yes

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

q30

Yes

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

q31

Yes

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

q32

Yes

BOX F – I HAVE/HAVE HAD:

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

q33

Yes

Back or spinal surgery within the last 12 months.

q34

Yes

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

q35

Yes

An uncorrected hernia that limits my physical abilities.

q36

Yes

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

q37

Yes

BOX G – I HAVE HAD:

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

q38

Yes

Dehydration requiring medical intervention within the last 7 days.

q39

Yes

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

q40

Yes

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

q41

Yes

Active or uncontrolled ulcerative colitis or Crohn’s disease.

q42

Yes

Bariatric surgery within the last 12 months.

q43

Yes

Phone

This field is for validation purposes and should be left unchanged.

Medical Questionnaire

Diver Medical | Participant Questionnaire

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. If any of the answer is YES, then please answer the revelant questions in boxes that appear in the second page

Participant Signature

Diver Medical | Participant Questionnaire Continued