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SCUBA DIVING, SNORKELING, TRAVEL AND RELATED ACTIVITIES WAIVER, STATEMENT OF UNDERSTANDING, AND RELEASE OF LIABILITY

This agreement is entered into between the undersigned individual (hereafter “Participant”) and Southern Utah Scuba LLC, including its owners, officers, employees, volunteers, independent contractors, agents, instructors, assistants, and any individuals involved in organizing, facilitating, or assisting with the scuba diving activities (collectively referred to as the “Released Parties”), in connection with scuba diving activities offered by Southern Utah Scuba LLC. Scuba diving activities include, but are not limited to, guided dives, group dive trips, shore diving, boat diving, travel to and from dive sites, use of rental or personal equipment, snorkeling, confined water sessions, open water activities, and any related instruction, supervision, or support services.


1. Acknowledgment of Risks

Participant understands that scuba diving involves inherent and serious risks, including but not limited to:

  • Drowning or near-drowning
  • Lung over-expansion injuries (air embolism, pneumothorax)
  • Decompression sickness
  • Barotrauma (ear, sinus, or lung injuries)
  • Nitrogen narcosis
  • Vertigo, disorientation, or panic
  • Equipment failure
  • Environmental hazards (cold, surf, marine life, visibility, depth)
  • Boat travel, boarding, and disembarking
  • Shore entries and exits over rocks, sand, or uneven terrain
  • Weather, sea state, currents, surge, and changing environmental conditions
  • Separation from group, buddy, or guide
  • Delayed or unavailable emergency medical care in remote or international locations

Participant acknowledges these risks exist even under supervision and with properly maintained equipment. Participant acknowledges that these risks cannot be eliminated and may be compounded by travel, location, environmental conditions, or the actions of other participants.

I Agree

2. Assumption of Risk

Participant accepts and assumes all risks, whether known or unknown, associated with scuba diving activities. These risks may result in injury, illness, permanent disability, or death. Participant understands that participation is entirely voluntary and elects to participate despite these risks.

I Agree

3. Release of Liability

Participant fully and forever releases and discharges the Released Parties from any and all liability, claims, or demands arising from injury, loss, or death occurring during or resulting from participation in scuba diving activities—even if caused by the negligence of the Released Parties.

Participant also agrees to indemnify and hold harmless the Released Parties from any claims brought against them related to Participant’s actions or participation.

This release applies to all claims, whether arising during training, guided dives, group trips, travel, or related activities, including those involving third-party operators, transportation providers, dive boats, accommodations, or facilities used in connection with Southern Utah Scuba activities.

I Agree

4. Medical Statement

Participant affirms they are in good health and fit to dive. Participant agrees to complete the scuba medical questionnaire below and, if required, obtain a physician’s clearance before participating. They affirm they are not under the influence of alcohol, drugs, or medication that may impair judgment or ability. Medical statements are valid for one (1) year from the date signed, or until any change in the Participant’s health status occurs, whichever occurs first.

I Agree

5. Certified Diver Responsibility

Certified diver participants acknowledge they are responsible for diving within the limits of their training, certification, and physical fitness. Divers agree to plan their dives conservatively, stay close to their buddy, stay within sight of the guide, monitor their own air supply, depth, bottom time, buoyancy, descent rate, ascent rate, and follow all standard safety practices.

The guide’s role is to provide site orientation, planning assistance, and safely lead the dive group, but divers are still expected to follow all other requirements outlined above. The guide assumes certified divers know basic hand signals and have either been diving or participated in a refresher course in the past year. Participant understands that a dive guide is not responsible for monitoring each diver’s air supply, depth, time, buoyancy, or physical condition. Each certified diver is solely responsible for their own dive decisions and safety.

Participant agrees to follow all instructions and immediately report discomfort, distress, low air pressure or any equipment issues.

I Agree

7. Equipment Use and Rental

Participant understands that scuba equipment, whether owned by Participant or rented or provided by Southern Utah Scuba or third parties, involves inherent risks. Participant accepts responsibility for inspecting equipment prior to use, reporting any issues, and using equipment properly.

Participant assumes all risks associated with the use, misuse, or failure of any equipment and releases the Released Parties from liability related to such equipment use, except where prohibited by law.

I Agree

6. Introductory and Refresher Participants

Participants engaging in introductory experiences or refresher sessions acknowledge that these are non-certification activities. These may include pool dives, confined water skills practice, or limited open water exposure under direct supervision.

Participant agrees to follow all instructions and immediately report discomfort, distress, low air pressure or any equipment issues.

I Agree

7. Property and Premises Risks

Participant understands that scuba diving activities may take place on private or public property, including but not limited to pool decks, walkways, yards, docks, rocky shorelines, grassy areas, and boat ramps. Participant acknowledges that wet, slippery, or uneven surfaces are common in these environments.

Participant voluntarily assumes all risks of slipping, tripping, or falling while on or near any property associated with scuba diving activities—before, during, or after participation. Participant agrees to release and hold harmless the Released Parties from any injuries, claims, or damages arising from such incidents, whether caused by negligence, the condition of the premises, or other factors.

I Agree

8. Private Property and Facility Use

Participant acknowledges that some activities may take place on private property (e.g., home pool) and agrees to respect the premises and all posted or verbal rules. The Released Parties are not responsible for any lost or damaged personal property.

I Agree

9. Media Use and Promotional Content

Photos and video may be taken during scuba diving activities. By participating, you grant Southern Utah Scuba the right to use any such media for marketing, training, or promotional purposes, including but not limited to online platforms, brochures, or social media.

If you do not wish to appear in photos or video used for such purposes, you must notify the business in writing prior to participating.

I Agree

10. Group Dive Trips and Travel

Participant understands that group dive trips may involve travel by automobile, van, boat, aircraft, or other means; lodging at hotels, resorts, or private accommodations; and diving operations conducted by third-party providers not under the direct control of Southern Utah Scuba.

Participant agrees that Southern Utah Scuba acts solely as an organizer and coordinator for such trips and is not responsible for the acts, omissions, or negligence of any third-party operators, transportation providers, accommodations, or guides.

Participant voluntarily assumes all risks associated with travel, lodging, and third-party services and releases the Released Parties from any related claims.

I Agree

11. Governing Law and Severability

This agreement shall be governed by the laws of the State of Utah, United States of America. If any portion of this waiver is deemed unenforceable, the remainder shall remain in full effect.

I Agree

11. Acknowledgment and Signature

I HAVE READ AND UNDERSTAND THIS ENTIRE DOCUMENT. I ACKNOWLEDGE THAT BY SIGNING IT, I AM GIVING UP LEGAL RIGHTS INCLUDING THE RIGHT TO SUE.

I Agree

If signing on behalf of a minor, I certify that I am the parent or legal guardian and agree to all terms on behalf of the minor.

Signature of Participant (or Parent/Guardian if under 18) 

 February 11, 2026 

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

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
Diver Medical Questionnaire

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

Directions

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

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

1) 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
2) I am over 45 years of age. *
No
Yes - Go to box B
3) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes - Requires Physician Approval
4) I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes - Go to box C
5) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes- Requires physician approval
6) 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
7) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.*
No
Yes - Go to box E
8) I have had back problems, hernia, ulcers, or diabetes.*
No
Yes - Go to box F
9) I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
10) I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes- Requires physician approval

Participant Instructions

If you answered NO to all 10 questions above, a medical evaluation is not required. You DO NOT need to review/answer the follow up questions in Boxes A-G.

 * If you answered YES to questions 3, 5 or 10 above OR to any required follow up questions to come in Boxes A through G, please read and agree to the participant statement by signing and dating this document AND go to https://www.dansa.org/dive-medical-forms to obtain a copy of this form (Participant Questionnaire and the Physician’s Evaluation Form) to fill out and have signed by your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Once signed by your physician, email a copy to jake@southernutahscuba.com or bring the signed form with you to the dive activity.

(Only if you answered YES to Question 1) 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- Requires physician approval
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes- Requires physician approval
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- Requires physician approval
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *
No
Yes- Requires physician approval
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *
No
Yes- Requires physician approval

(Only if you answered YES to question 2) BOX B – I AM OVER 45 YEARS OF AGE AND: 

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

(Only if you answered YES to question 4) BOX C – I HAVE/HAVE HAD: 

Sinus surgery within the last 6 months. *
No
Yes- Requires physician approval
Ear disease or ear surgery, hearing loss, or problems with balance. *
No
Yes- Requires physician approval
Recurrent sinusitis within the past 12 months. *
No
Yes- Requires physician approval
Eye surgery within the past 3 months. *
No
Yes- Requires physician approval

(Only if you answered YES to question 6) BOX D – I HAVE/HAVE HAD: 

Head injury with loss of consciousness within the past 5 years. *
No
Yes- Requires physician approval
Persistent neurologic injury or disease. *
No
Yes- Requires physician approval
Recurring migraine headaches within the past 12 months, or take medications to prevent them. *
No
Yes- Requires physician approval
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *
No
Yes- Requires physician approval
Epilepsy, seizures, or convulsions, OR take medications to prevent them. *
No
Yes- Requires physician approval

(Only if you answered YES to question 7) BOX E – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 8) BOX F – I HAVE/HAVE HAD: 

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

(Only if you answered YES to question 9) BOX G – I HAVE HAD: 

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

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

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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