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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.
1
I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.
Yes
No
I have/have had:
Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
Yes
No
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
Yes
No
A diagnosis of COVID-19.
Yes
No
2
I am over 45 years of age.
Yes
No
I am over 45 years of age AND:
I currently smoke or inhale nicotine by other means.
Yes
No
I have a high cholesterol level.
Yes
No
I have high blood pressure.
Yes
No
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
Yes
No
3
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.
Yes
No
4
I have had problems with my eyes, ears, or nasal passages/sinuses.
Yes
No
I have/have had:
Sinus surgery within the last 6 months.
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.
Yes
No
Recurrent sinusitis within the past 12 months.
Yes
No
Eye surgery within the past 3 months.
Yes
No
5
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
Yes
No
6
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
Yes
No
I have/have had:
Head injury with loss of consciousness within the past 5 years.
Yes
No
Persistent neurologic injury or disease.
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.
Yes
No
7
I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.
Yes
No
I have/have had:
Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.
Yes
No
8
I have had back problems, hernia, ulcers, or diabetes.
Yes
No
I have/have had:
Recurrent back problems in the last 6 months that limit my everyday activity.
Yes
No
Back or spinal surgery within the last 12 months.
Yes
No
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.
Yes
No
An uncorrected hernia that limits my physical abilities.
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
Yes
No
9
I have had stomach or intestine problems, including recent diarrhea.
Yes
No
I have had:
Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Yes
No
Dehydration requiring medical intervention within the last 7 days.
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Yes
No
Active or uncontrolled ulcerative colitis or Crohn’s disease.
Yes
No
Bariatric surgery within the last 12 months.
Yes
No
10
I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).
Yes
No

Participant Signature

Please read and agree to the participant statement below by signing 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.
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