Today's Date: January 24, 2022
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 NAUI Instructor immediately and complete a new NAUI medical history form for inclusion in your student file.