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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.


Today's Date: April 27, 2026

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Date of Birth
Information

Directions

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

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


 * If you answer YES to questions 3, 5 or 10 below OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Medical evaluation is required


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

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes - Go to box A
I am over 45 years of age. *
No
Yes - Go to box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.*
No
Yes - Go to box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.*
No
Yes - Go to box D
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 or developmental disability.*
No
Yes - Go to box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
I am taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]). *
No
Yes

Participant Signature

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
Facility Name

BOX A – I HAVE/HAVE HAD: 

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
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.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes

BOX B – I AM OVER 45 YEARS OF AGE AND: 

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
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).*
No
Yes

BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes
Recurrent sinusitis within the past 12 months. *
No
Yes
Eye surgery within the past 3 months. *
No
Yes
Still healing / recovering from recent dental / oral procedure. *
No
Yes

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance. *
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes
Epilepsy, seizures, or convulsions, take medications to prevent them. *
No
Yes

BOX E – I HAVE/HAVE HAD: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years. *
No
Yes

BOX F – I HAVE/HAVE HAD: 

Recurrent back problems in the last 6 months that limit my everyday activity. *
No
Yes
Back or spinal surgery within the last 12 months. *
No
Yes
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *
No
Yes
An uncorrected hernia that limits my physical abilities. *
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *
No
Yes

BOX G – I HAVE HAD: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *
No
Yes
Dehydration requiring medical intervention within the last 7 days. *
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *
No
Yes
Active or uncontrolled ulcerative colitis or Crohn’s disease. *
No
Yes
Bariatric surgery within the last 12 months. *
No
Yes
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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