Loading...

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.

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.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Third Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Fourth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Fifth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Sixth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Seventh Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Eighth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Ninth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Tenth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


Parent or Guardian's Email Address

Email*

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

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No - Go to Question 2
Yes ( Complete below Box A )

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes - *Physician's medical evaluation required
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes - *Physician's medical evaluation required
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.*
No
Yes - *Physician's medical evaluation required
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes - *Physician's medical evaluation required
A diagnosis of COVID-19.*
No
Yes - *Physician's medical evaluation required

2. I am over 45 years of age.*
No - Go to Question 3
Yes ( Complete below Box B )

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
No
Yes - *Physician's medical evaluation required
I have a high cholesterol level.*
No
Yes - *Physician's medical evaluation required
I have high blood pressure.*
No
Yes - *Physician's medical evaluation required
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).*
No
Yes - *Physician's medical evaluation required

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.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No -Go to Question 5
Yes ( Complete below Box C )

Box C - I have/have had:

Sinus surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes - *Physician's medical evaluation required
Recurrent sinusitis within the past 12 months.*
No
Yes - *Physician's medical evaluation required
Eye surgery within the past 3 months.*
No
Yes - *Physician's medical evaluation required

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No - Go to Question 7
Yes ( Complete below Box D )

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
No
Yes - *Physician's medical evaluation required
Persistent neurologic injury or disease.*
No
Yes - *Physician's medical evaluation required
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes - *Physician's medical evaluation required
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes - *Physician's medical evaluation required
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes - *Physician's medical evaluation required

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.*
No - Go to Question 8
Yes ( Complete below Box E )

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes - *Physician's medical evaluation required
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
No
Yes - *Physician's medical evaluation required
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes - *Physician's medical evaluation required

8. I have had back problems, hernia, ulcers, or diabetes.*
No - Go to Question 9
Yes ( Complete below Box F )

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes - *Physician's medical evaluation required
Back or spinal surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes - *Physician's medical evaluation required
An uncorrected hernia that limits my physical abilities.*
No
Yes - *Physician's medical evaluation required
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required

9. I have had stomach or intestine problems, including recent diarrhea.*
No - Go to Question 10
Yes ( Complete below Box G )

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes - *Physician's medical evaluation required
Dehydration requiring medical intervention within the last 7 days.*
No
Yes - *Physician's medical evaluation required
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes - *Physician's medical evaluation required
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes - *Physician's medical evaluation required
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes - *Physician's medical evaluation required
Bariatric surgery within the last 12 months.*
No
Yes - *Physician's medical evaluation required

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement 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.


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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!