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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.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
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.
Please check the box for applicable medical conditions:
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
COVID
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
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: Please specify below

Please explain any box you checked:

If you are over 40 of ageand can answer yes to any of following:   

Current Smoke:*
No
Yes
High blood pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

List all Medications you are presently taking:

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

If at any time 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.

FOR TRIPS ...you need a medical note clearing you for diving


TRIP INSURANCE NAME AND NUMBER: *

DAN MEMBERSHIP TYPE AND NUMBER: *
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 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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