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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.

SSI Recreational Scuba Training Assumption of Risk, Liability Release & Hold Harmless Agreement

(Form not to be used within the European Union and various other countries depending on local laws/regulations - The Training Center and the Professionals are responsible to know and adhere to laws/local regulations) This is a legal contract terminating your rights to file a lawsuit. Read carefully before signing. Warning – Scuba diving uses life-support equipment and techniques that have inherent risks which may cause serious injury, illness or death.

In consideration of being allowed to participate in scuba training, I, expressly agree to be bound by this Agreement and comply with the SSI Responsible Scuba Diver Code. I understand this Agreement is between me, my family, estate, heirs and or anyone who may have a claim on my behalf; and American Reef Scuba, including all instructors, facilities, boats, and training sites I receive training with or at; Scuba Schools International (“SSI”); and each of their respective owners, officers, employees, representatives, volunteers, agents, contractors and any others on their behalves, whether specifically named or not (herein referred to as “Released Parties”).

I voluntarily assume all risks of injury, illness and death, caused by scuba diving and all related activities, whether foreseeable or not, including but not limited to risks associated with: swimming, entering and exiting the water, falling on, struck by or abandoned by a boat, separation or lost underwater, holding my breath, pre-existing health conditions, heart failure, over-exertion, panic, drowning, pressure related injuries, decompression illness, environmental and marine life injuries, unknown causes, equipment malfunctions, improper dive planning, or improper action of other divers or support personnel (including failure to rescue, recover, resuscitate, or provide emergency assistance).

I agree to waive, release, not sue, discharge, save, indemnify, and hold harmless the Released Parties of all claims, demands, causes of action, lawsuits and damages by me, my estate, family (including minor children), heirs, or others who may have a claim for my injury, illness or death as a result of any act or failure to act, including negligence by the Released Parties, associated with my scuba training and all related activities. I agree that it is my responsibility to inform my family and all those who may have legal rights on my behalf that I have entered into this Agreement and it is my intent that they be bound by this Agreement. I agree that me or my estate shall be fully liable (pay for) for the cost to the Released Parties for any claim brought on my behalf as a consequence of my participation in scuba diving and all related activities.

I have carefully read, understand and agree to comply with the SSI Responsible Scuba Diver Code during all diving activities. I understand and agree that I am responsible for my own safety and well-being during all dive training and related activities. I am responsible for being physically, medically and mentally fit to participate in scuba diving. I affirm that all personal information I have provided on medical questionnaires is truthful and accurate to the best of my knowledge, and I will not hold others responsible or liable for any injury, illness or death caused by my failure to disclose a known medical condition. I am responsible for my own equipment configuration, assembly, and pre-dive inspection to verify it is appropriate and functioning properly. I am responsible for planning and performing all my dive activities, including anticipating potential emergencies. I will not hold anyone, including the Released Parties, responsible for failure to protect my well-being, ensure my proper use of equipment, or conduct my dive activities competently. I will not dive in conditions or at times that are not within my abilities and comfort level. If conditions become dangerous or I do not feel well or I become injured, I will immediate notify the dive leader and take action to correct the situation. I understand dive activities are conducted at sites that are remote, in time and distance, from medical care or a recompression chamber. I understand dive training does not guarantee my safety and that accidents happen even when proper procedures are followed. I understand the importance of, and my responsibility to have, personal insurance that specifically covers dive-related emergencies, emergency transportation, and medical treatments.

I understand and agree that SSI licenses training centers, professionals and their affiliates to use various SSI trademarks and to conduct SSI approved training, but they are not agents, employees or franchisees of SSI, its parent, subsidiary, or affiliated corporations. I further understand that SSI training centers, SSI professionals, and their affiliates’ businesses are independent, and are neither owned, operated, or controlled by SSI, and that while SSI establishes standards and materials for SSI training, it is not responsible for, nor does it have the right to control, the operation of the business activities or the day-to-day training and/or supervision of divers by SSI training centers, SSI professionals, their affiliated businesses, and/or their associated staff. I further understand and agree on behalf of myself, that in the event of injury, illness or death during dive activities, I shall not hold SSI liable for the actions, inactions or negligence of the SSI training center, SSI professionals and other affiliated businesses or personnel associated with my dive activities.

I have read this Agreement and the SSI Responsible Scuba Diver Code. I expressly understand my responsibilities and that I am giving up legal rights by signing this Agreement. I understand this is a legal contract and I am voluntarily signing it without duress or further inducement. I understand this is an unconditional and complete release of all liability to the greatest extent allowed by law. If any portion of this Agreement is found to be legally unenforceable or invalid, that portion shall be severed, and the remainder shall have full force and effect. I agree to be bound by this Agreement without modification of the preprinted text. The terms of this Agreement shall continue in effect for all scuba diving training (including entry-level training and continuing education training) and related activities for a period of one year from the date I signed this agreement. I am over 18 years of age and legally competent to engage in this Agreement, or I have acquired the written consent of my parent or guardian by completing a Youth Addendum form.

Today's Date: September 4, 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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. 
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), OR 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.*
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.*
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 prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

Participant Signature

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

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.

 * If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND please ask us for a printed form (Participant Questionnaire and the Physician’s Evaluation Form) to have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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

BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes
Persistent neurologic injury or disease. *
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, OR 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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