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PADI Medical Questionnaire

This is a preliminary medical questionnaire, you will be filling this out at the dive site.  You must complete this medical statement at the dive site, which includes the medical questionnaire section, to enroll in the scuba training program.  If you are a minor, you must have this Statement signed by a parent or guardian.  

Scuba diving is an exciting and demanding activity. To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor before participating in this program.

The purpose of this Medical Questionnaire is to find out if you should be examined by a physician before participating in recreational scuba diving. 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 advice of a physician.

Please answer the following questions on your past and present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to a physician.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email
Check to receive information regarding your tour, updates, and future discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
PADI Medical Questionaire
Do you currently have an ear infection?*
Do you have a history of ear disease, hearing loss or problems with balance?*
Do you have a history of ear or sinus surgery?*
Are you currently suffering from a cold, congestion, sinusitis or bronchitis?*
Do you have a history of respiratory problems, severe attacks or hay fever or allergies, or lung disease?*
Have you had a collapsed lung (pneumothorax) or a history of chest surgery?*
Do you have active asthma or history of emphysema or tuberculosis?*
Are you currently taking medication that carries warning about any impairment of your physical or mental abilities?*
Do you have behavioral health, mental or psychological problems or a nervous system disorder?*
Are you or could you be pregnant?*
Do you have a history of colostomy?*
Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?*
Are you over 45 and have a family history of heart attack or stroke?*
Do you have a history of bleeding or other blood disorders?*
Do you have a history of diabetes?*
Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?*
Do you have a history of back, arm or leg problems following an injury, fracture or surgery?*
Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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