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.

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

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

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?

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE.... Asthma, or wheezing with breathing, or wheezing with exercise?

Frequent or severe attacks of hayfever or allergy?

Frequent colds, sinusitis or bronchitis?

Any form of lung disease?

Pneumothorax (collapsed lung)?

Other chest disease or chest surgery?

Behavioural health, mental or psychological problems (panic attack, fear of closed or open spaces)?

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

Recurring migraine, headaches or take medications to prevent 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 ro perform moderate exercise (example: walk 1,6km/1 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 medication to control blood pressure?

Heart disease?

Heart attack?

Angina, heart surgery or blood vessel surgery?

Sinus suregery?

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 last five years?

14 + 14 =

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