Medical Questionnaire Diving

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 advise of your physician.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of there items apply to you, we must request that you consult with a physician prior to participating in scuba diving.

Full Name

Email Address

Could you be pregnant, or are you attempting to become pregnant? Could you be pregnant, or are you attempting to become pregnant? Yes No

Are you presently taking prescription medications? (with exception for birth control or anti-malarial) Are you presently taking prescription medications? (with exception for birth control or anti-malarial) Yes No

Are you over 45 years of age and can answer yes to any of the following: Currently smoking pipe, ciggars or cigarets? Having a high cholesterol level? Having a family history of heart attacks or strokes? Are currently receiving medical care? High blood pressure? Diabetes mellitus, even if controlled by diet alone? Are you over 45 years of age and can answer yes to any of the following: Currently smoking pipe, ciggars or cigarets? Having a high cholesterol level? Having a family history of heart attacks or strokes? Are currently receiving medical care? High blood pressure? Diabetes mellitus, even if controlled by diet alone? Yes No

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE.... Asthma, or wheezing with breathing, or wheezing with exercise? HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE.... Asthma, or wheezing with breathing, or wheezing with exercise? Yes No

Frequent or severe attacks of hayfever or allergy? Frequent or severe attacks of hayfever or allergy? Yes No

Frequent colds, sinusitis or bronchitis? Frequent colds, sinusitis or bronchitis? Yes No

Any form of lung disease? Any form of lung disease? Yes No

Pneumothorax (collapsed lung)? Pneumothorax (collapsed lung)? Yes No

Other chest disease or chest surgery? Other chest disease or chest surgery? Yes No

Behavioural health, mental or psychological problems (panic attack, fear of closed or open spaces)? Behavioural health, mental or psychological problems (panic attack, fear of closed or open spaces)? Yes No

Epilepsy, seizures, convulsions or take medications to prevent them? Epilepsy, seizures, convulsions or take medications to prevent them? Yes No

Recurring migraine, headaches or take medications to prevent them? Recurring migraine, headaches or take medications to prevent them? Yes No

Blackouts or fainting (full/partial loss of consciousness)? Blackouts or fainting (full/partial loss of consciousness)? Yes No

Frequent or severe suffering from motion sickness (seasick, carsick etc.)? Frequent or severe suffering from motion sickness (seasick, carsick etc.)? Yes No

Dysentery or dehydration requiring medical intervention? Dysentery or dehydration requiring medical intervention? Yes No

Any dive accidents or decompression sickness? Any dive accidents or decompression sickness? Yes No

Inability ro perform moderate exercise (example: walk 1,6km/1 mile within 12 mins.)? Inability ro perform moderate exercise (example: walk 1,6km/1 mile within 12 mins.)? Yes No

Head injury with loss of consciousness in the past five years? Head injury with loss of consciousness in the past five years? Yes No

Recurrent back problems? Recurrent back problems? Yes No

Back or spinal surgery? Back or spinal surgery? Yes No

Diabetes? Diabetes? Yes No

Back, arm or leg problems following surgery, injury or fracture? Back, arm or leg problems following surgery, injury or fracture? Yes No

High blood pressure or take medication to control blood pressure? High blood pressure or take medication to control blood pressure? Yes No

Heart disease? Heart disease? Yes No

Heart attack? Heart attack? Yes No

Angina, heart surgery or blood vessel surgery? Angina, heart surgery or blood vessel surgery? Yes No

Sinus suregery? Sinus suregery? Yes No

Ear disease or surgery, hearing loss or problems with balance? Ear disease or surgery, hearing loss or problems with balance? Yes No

Recurrent ear problems? Recurrent ear problems? Yes No

Bleeding or other blood disorders? Bleeding or other blood disorders? Yes No

Hernia? Hernia? Yes No

Ulcers or ulcer surgery? Ulcers or ulcer surgery? Yes No

A colostomy or ileostomy? A colostomy or ileostomy? Yes No

Recreational drug use or treatment for, or alcoholism in the last five years? Recreational drug use or treatment for, or alcoholism in the last five years? Yes No

Data Privacy Policy Data Privacy Policy I have read and agree with the Data Privacy Policy

Number

12 + 7 =

Thank you for answering this questionnaire. If there are any questions that will arise when reviewing this we will contact you with consultation.