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.
I am currently suffering from a cold or congestion.
I have a history of respiratory problems or disease.
I have had asthma, emphysema or tuberculosis.
I currently have an ear infection.
I have recurrent ear problems, ear disease or surgery.
I have a history of sinus problems.
I have had problems equalizing (popping) my ears with airplane or mountain travel.
I am diabetic.
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).
I have a history of seizures, dizziness or fainting.
I have a nervous system disorder.
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or
I have recurrent back problems, history of back or spinal surgery.
I am currently taking prescription medication that carries a warning about impairment of physical
and mental abilities (with the exception of anti-malarial).
I have recently had an operation or illness.
I am under the care of a physician or have a chronic illness.