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Emergency Contact

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MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant’s past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician.
q1*
I am currently suffering from a cold or congestion.
q2*
I have a history of respiratory problems or disease.
q3*
I have had asthma, emphysema or tuberculosis.
q4*
I currently have an ear infection.
q5*
I have recurrent ear problems, ear disease or surgery.
q6*
I have a history of sinus problems.
q7*
I have had problems equalizing (popping) my ears with airplane or mountain travel.
q8*
I am diabetic.
q9*
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).
q10*
I have a history of seizures, dizziness or fainting.
q11*
I have a nervous system disorder.
q12*
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).
q13*
I have recurrent back problems, history of back or spinal surgery.
q14*
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).
q15*
I have recently had an operation or illness.
q16*
I am under the care of a physician or have a chronic illness.