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Read this statement prior to signing it. You must complete this additional medical questionnaire to enroll in a diver training program or to participate in any diving activity. If you are a minor, you must have this statement signed by your parent or guardian.

DIVER MEDICAL QUESTIONNAIRE

The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Please answer the following questions with a YES or NO. A positive response means that there may be a preexisting condition that could affect your safety while diving. If any of these items apply to you, you should consult with a physician, preferably a specialist in diving medicine, prior to participating in diving activities.

ADDITIONAL DECLARATIONS / COVID-19

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by Culebra Divers Culebra Divers staff members, and will take all reasonable preventive steps that may be recommended by Culebra Divers staff members, or any relevant public authority.

I Agree

I WILL accept and observe all instructions by Culebra Divers staff members and intend to abide by all existing regulations required tohelp prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities.

I Agree

I ACKNOWLEDGE and ACCEPT that this declaration will be consideredas my consent to Culebra Divers to retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.

I Agree

PLEASE NOTE

COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalescence before returning to full activities – a process that can take weeks or months depending on symptom severity (1).

MEDICAL RECOMMENDATIONS (2, 3):

  • Divers who have tested positive for COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.
  • Divers who have had symptomatic COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a medical professional.
  • Divers who have been hospitalized with or because of pulmonary symptoms in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a medical professional, with complete pulmonary function testing and an exercise test with peripheral oxygen saturation measurement as well as a high resolution CT scan of the lungs.
  • Divers who have been hospitalized with or because of cardiac problems in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a medical professional that includes a cardiac evaluation, including echocardiography and an exercisetest (exerciseelectrocardiography).

REFERENCES

(1)  Return to Diving Post COVID-19 - Issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA

(2)  Diving after COVID-19 pulmonary infection - Position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG)

(3)  Recreational and professional diving after the Coronavirus disease (COVID-19) outbreak - Position statement of EUBS & ECHM

Today's Date: December 2, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Date of Tour *

Within the 40 days immediately preceding the date of this Health Declaration Form, have you: 

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR SARS-COV-2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*
No
Yes
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*
No
Yes
3. BEEN IN DIRECT CONTACT WITH, OR IN THE IMMEDIATE VICINITY OF, ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONA VIRUS OR WHO WAS DIAGNOSED ASP OSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*
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 any omissions in disclosing my existing or past health conditions.


I also commit to inform Culebra Divers about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

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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