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MEDICAL STATEMENT

Participant Record (Confidential Information) 

rev 6/07

This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by Puerto Rico Diving, Inc. dba Rincon Diving & Snorkeling, and its Instructor(s) located in the Facility Pueblo of Rincon_, Puerto Rico

Read this statement prior to signing it. You must complete this Medical Statement, 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. Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks. To scuba dive safely, you should 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 coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely. If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing

 

DIVERS MEDICAL QUESTIONAIRE

To the Participant:

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 advice of your physician prior to engaging in dive activities.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE: 

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes

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 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 an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
_ Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. 

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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