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Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

Today's date: May 8, 2024

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Diver Medical Questionnaire
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -You Must Also Complete Box A Below
No
2. I am over 45 years of age.*
Yes - You Must Also Complete Box B Below
No
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - You Must Also Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - You Must Also Complete Box D Below
No
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
Yes - You Must Also Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - You Must Also Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - You Must Also Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box A (Only Required if Question 1 Above Answered YES)

I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical and mental performance. *
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No


Box B (Only Required if Question 2 Above Answered YES)

I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
I have a high cholesterol level.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
I have high blood pressure.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box C (Only Required if Question 4 Above Answered YES)

I have/have had:

Sinus surgery within the last 6 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Recurrent sinusitis within the past 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Eye surgery within the past 3 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box D (Only Required if Question 6 Above Answered YES)

I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Persistent neurologic injury or disease.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box E (Only Required if Question 7 Above Answered YES)

I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box F (Only Required if Question 8 Above Answered YES)

I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Back or spinal surgery within the last 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
An uncorrected hernia that limits my physical abilities.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box G (Only Required if Question 9 Above Answered YES)

I have/had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Dehydration requiring medical intervention within the last 7 days.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Bariatric surgery within the last 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

If you answered NO to all 10 primary questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive center and take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

Instructor Name : Referenced In Divers Supply Member Instructors Addendum

Facility: Outdoor Adventures Inc., Charlie Marketing Inc., Divers Supply Inc. DBA Divers Supply


_____________________________________________                 

Participant Signature (In Person At Start of Training)   


_____________________________________________

Date Signed In Person       

I the participant listed on this medical questionnaire affirm that the information I provided on this form remains true and accurate and represents my current medical condition on this date signed by me in person.  

First Participant's Signature*
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.


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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Diver Medical Questionnaire
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -You Must Also Complete Box A Below
No
2. I am over 45 years of age.*
Yes - You Must Also Complete Box B Below
No
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - You Must Also Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - You Must Also Complete Box D Below
No
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
Yes - You Must Also Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - You Must Also Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - You Must Also Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box A (Only Required if Question 1 Above Answered YES)

I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical and mental performance. *
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No


Box B (Only Required if Question 2 Above Answered YES)

I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
I have a high cholesterol level.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
I have high blood pressure.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box C (Only Required if Question 4 Above Answered YES)

I have/have had:

Sinus surgery within the last 6 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Recurrent sinusitis within the past 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Eye surgery within the past 3 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box D (Only Required if Question 6 Above Answered YES)

I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Persistent neurologic injury or disease.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box E (Only Required if Question 7 Above Answered YES)

I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box F (Only Required if Question 8 Above Answered YES)

I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Back or spinal surgery within the last 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
An uncorrected hernia that limits my physical abilities.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

Box G (Only Required if Question 9 Above Answered YES)

I have/had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Dehydration requiring medical intervention within the last 7 days.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No
Bariatric surgery within the last 12 months.*
Yes - You will require Medical Clearance to dive from your Primary Care Physician. Please contact your dive center for the appropriate forms.
No

If you answered NO to all 10 primary questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive center and take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

Instructor Name : Referenced In Divers Supply Member Instructors Addendum

Facility: Outdoor Adventures Inc., Charlie Marketing Inc., Divers Supply Inc. DBA Divers Supply


_____________________________________________                 

Participant Signature (In Person At Start of Training)   


_____________________________________________

Date Signed In Person       

I the participant listed on this medical questionnaire affirm that the information I provided on this form remains true and accurate and represents my current medical condition on this date signed by me in person.  

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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