Medical questionnaire for divers

These are some medical conditinos that can be dangerous while scuba diving, which are listed below. Those who have or have the predisposition to suffer any of these conditions may be checked by a doctor. This Diver’s Physician Questionnaire provides a basic background for determining wheteher you should seek medical evaluation. If you have any concerns about your fitness for diving and are not represented on this form, please consult your physician prior diving. References to “diving” on this form include both recreational scuba divng and freeding. This form is primarily designed as a basic medical check for new divers, but it is also appropriate for divers receiving continuing education. For your safety and those diving with you, please answer all questions honestly.

Instructions

Complete this questionnaire as a prerequisite for freediving or scuba diving training.
 
** Important notice for women: If you are pregnant, or trying to be, do not dive.

Personal information




Medical information

1. I have had problems with my lungs or breathing, heart or blood *
YESNO

2. I am over 45 years old *
YESNO

3. I have difficulty doing moderate exercise (for example, walking 1.6 kilometers in 12 minutes or swimming 200 meters without resting), or I have not been able to participate in normal physical activity due to physical or health reasons in the last 12 months. *
YESNOT

4. I have had problems with my eyes, ears, or nasal passages or sinuses *
YESNOT

5. I have had surgery in the past 12 months, or have ongoing problems related to a previous surgery *
YESNOT

6. I have lost consciousness, have had migraine headaches, seizures, stroke, significant head injury, or have suffered from persistent neurological injury or disease *
YESNOT

7. I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or a drug or alcohol addiction *
YESNOT

8. I have had back problems, hernia, ulcers or diabetes *
YESNOT

9. I have had stomach or intestinal problems, including recent diarrhea *
YESNOT

10. I am taking prescription drugs (with the exception of birth control or antimalarial drugs) *
YESNOT

  I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any question that may have been answered inaccurately or for failure to disclose any existing or past health conditions. *

I am of age: YESNOT



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