Medical Questionnaire

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.
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

Who will be participating?

Adult  Children

Signee Information

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

Diver Medical | Participant Questionnaire Continued

If you have answered Yes to questions, 1, 2, 4, 6, 7, 8, or 9 - Please continue to the designated Box and answer the questions as required. If you answered NO to questions 1 thru 10 please scroll down to the bottom of the form and complete the signature requirements.

BOX A – I HAVE/HAVE HAD:








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







BOX C – I HAVE/HAVE HAD:







BOX D – I HAVE/HAVE HAD:








BOX E – I HAVE/HAVE HAD:







BOX F – I HAVE/HAVE HAD:








BOX G – I HAVE HAD:









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.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions located in Box’s A thru G, please read, and agree to the statement above by signing and dating it. An instructor will contact you with further instructions and will send you the Participant Questionnaire and the Physician’s Evaluation Form which you will need to bring to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

* Optional:

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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.