Today's Date: June 2, 2023
MEDICAL HISTORY INFORMATION FORM
MEDICAL HISTORY STATEMENT: I understand that skin and SCUBA diving are strenuous activities involving significant pressure changes and that normal, healthy heart, lungs, ear and sinus, are essential prerequisites for my safety and well-being. I hereby confirm that to the best of my knowledge my circulatory and respiratory systems and body air spaces are healthy and normal and that I have no severe emotional or neurological problems or communicable diseases. I understand that I need to seek unconditional approval for diving from a licensed physician if I am uncertain as to my physical fitness for the rigors of diving.
If at anytime during your dive training your medical condition changes, notify your Instructor immediately and complete a new medical history form for inclusion in your student file.
If you are over 45 of age answer yes/no to any of following:
You will need a medical note if any of the above questions are marked Y
I certify that the above information is correct to the best of my knowledge.