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MEDICAL FORM

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.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

Parent or Guardian's Email Address

Email*

Confirm Email*
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*
Parent or Guardian's Information
Write YES or NO next to all of the following that apply: *
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
COVID
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed

Explain in detail any and all of the boxes you checked: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked Y

certify that the above information is correct to the best of my knowledge.

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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