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SCUBA DIVING, SNORKELING, TRAVEL AND RELATED ACTIVITIES

ACKNOWLEDGMENT OF RISKS, ASSUMPTION OF RISK, AND RELEASE OF LIABILITY

PLEASE READ CAREFULLY. THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS AND INCLUDES A RELEASE OF CLAIMS FOR ORDINARY NEGLIGENCE.

1. Parties and Covered Activities

This agreement is between the undersigned participant (“Participant”) and Southern Utah Scuba LLC, doing business as Coral Escapes (“Company”).

“Released Parties” means Company and its members, managers, officers, employees, instructors, assistants, volunteers, agents, and independent contractors, in their respective capacities organizing, providing, facilitating, or assisting with the Activities.

“Activities” means the activities provided, organized, or arranged by Company in connection with the trip, course, program, or session identified below. Activities may include:

  • Scuba certification courses, introductory experiences, refresher sessions, confined water sessions, open water training, and guided or group dives.
  • Shore diving, boat diving, snorkeling, swimming, and water entries and exits.
  • Use of personal, rented, or provided equipment.
  • Group travel, transportation, lodging, and use of pools, villas, resorts, boats, docks, and other facilities.
  • Excursions, recreational activities, and wellness services arranged by Company.
  • Associated briefings, preparation, equipment handling, and support services.

This agreement applies to the following trip, course, program, or session, including its associated Activities:

Trip:Cozumel Private Paradise Villa Retreat

Date or date range: October 26th-November 2nd, 2026

Participant acknowledgment: 

I Agree

2. Acknowledgment of Risks

Participant understands that the Activities involve inherent and other risks that may cause property damage, injury, illness, permanent disability, or death.

Risks associated with scuba diving, snorkeling, swimming, and related water activities include:

  • Drowning, near-drowning, or aspiration of water.
  • Pulmonary overexpansion injuries, including arterial gas embolism and pneumothorax.
  • Decompression sickness.
  • Ear, sinus, lung, or other pressure-related injuries.
  • Nitrogen narcosis, oxygen toxicity, and breathing-gas problems.
  • Vertigo, disorientation, anxiety, panic, fatigue, or loss of consciousness.
  • Equipment malfunction, failure, improper adjustment, or misuse.
  • Running low on or exhausting breathing gas.
  • Separation from a buddy, guide, group, boat, or exit point.
  • Cold, heat, depth, reduced visibility, currents, surf, surge, weather, and changing conditions.
  • Marine life injuries and contact with sharp, abrasive, or hazardous surfaces.
  • Boat movement, propellers, boarding, disembarking, and shore entries and exits.

Risks associated with travel, lodging, premises, and other Activities include transportation accidents; wet, slippery, uneven, or unfamiliar surfaces; stairs, docks, decks, and pools; physical exertion; foodborne or infectious illness; allergic reactions; theft or loss of property; and the actions or omissions of other participants or service providers.

Some Activities occur in remote or international locations where rescue, emergency oxygen, medical treatment, evacuation, or recompression facilities may be delayed, limited, or unavailable. Medical services and safety practices may differ from those available at home.

Participant understands that these risks can exist despite supervision, planning, precautions, and properly maintained equipment. No instructor, guide, operator, or organizer can guarantee safety or eliminate all risks.

Participant acknowledgment:

I Agree

3. Voluntary Participation and Assumption of Risk

Participant voluntarily chooses to participate in the Activities with knowledge of the risks described above.

To the fullest extent permitted by applicable law, Participant accepts and assumes the risks of participation, whether known or unknown, including risks arising from environmental conditions, equipment, other participants, independent service providers, and the ordinary negligence of the Released Parties.

Participant may decline an Activity or stop participating if uncomfortable, unwell, inadequately prepared, or concerned about conditions. Participant agrees to communicate those concerns promptly and follow applicable procedures for safely ending participation.

Participant acknowledgment:

I Agree

4. Release of Liability for Ordinary Negligence

TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW, PARTICIPANT RELEASES AND DISCHARGES THE RELEASED PARTIES FROM CLAIMS FOR PERSONAL INJURY, ILLNESS, DEATH, OR PROPERTY LOSS OR DAMAGE ARISING OUT OF OR RELATED TO THE ACTIVITIES, INCLUDING CLAIMS CAUSED BY THE ORDINARY NEGLIGENCE OF A RELEASED PARTY.

This release includes ordinary-negligence claims relating to organizing or conducting Activities; instruction, guiding, or supervision; equipment selection, provision, inspection, or maintenance; premises used for Activities; and arranging transportation, lodging, or other services.

This agreement does not release gross negligence, reckless or intentional misconduct, or any liability that cannot lawfully be waived.

Participant acknowledgment: 

I Agree

5. Responsibility for Harm to Others

To the fullest extent permitted by applicable law, Participant agrees to indemnify and hold harmless the Released Parties from third-party claims for injury or property damage to the extent caused by Participant’s negligent or intentional misconduct during the Activities.

This obligation is limited to the portion of loss attributable to Participant’s conduct. It does not require Participant to indemnify a Released Party for that party’s own negligence, reckless or intentional misconduct, or other liability that cannot lawfully be shifted.

This section does not require a parent or guardian to reimburse the Released Parties merely because a minor asserts a claim.

Participant acknowledgment: 

I Agree

6. Medical Disclosure and Fitness to Participate

Participant agrees to complete the accompanying medical questionnaire fully and accurately and to follow its instructions. When physician approval is required, Participant must obtain and provide that approval before diving.

Participant agrees to disclose any condition, symptom, injury, illness, medication, or change in health that may affect safe participation. Participant will notify Company before the next Activity if relevant information changes after completing the questionnaire or receiving physician approval.

Participant will not participate while impaired by alcohol, drugs, medication, fatigue, illness, or another condition that compromises judgment or ability.

Company requires a new medical questionnaire at least annually and sooner following a relevant health change. More frequent screening or updated physician approval may be required by the questionnaire, physician, training agency, operator, insurer, or applicable rules. A previous questionnaire or physician approval does not guarantee present fitness to dive.

Company may postpone or decline participation when required medical information or approval is missing or when safety concerns arise.

Participant acknowledgment:

I Agree

7. Certified Diver Responsibilities

This section applies to certified divers participating outside an instructional activity requiring a different level of supervision.

Participant agrees to:

  • Accurately disclose certification level, relevant experience, date of last dive, and concerns about current skills or comfort.
  • Dive within the limits of training, certification, experience, equipment, and physical condition.
  • Participate in a refresher or skills assessment when required by Company or the dive operator.
  • Follow the dive briefing, buddy procedures, applicable limits, and emergency procedures.
  • Monitor breathing-gas supply, depth, dive time, buoyancy, descent and ascent rates, and physical condition.
  • Maintain buddy contact and remain with the guided group as directed by the briefing.
  • Promptly communicate low breathing gas, discomfort, distress, equipment problems, or a desire to end the dive.

A guide provides site orientation and dive leadership but cannot continuously monitor every diver or guarantee safety. Participant remains responsible for personal dive decisions and for communicating problems.

These participant responsibilities do not eliminate duties imposed on instructors or guides by applicable law or professional standards.

Participant acknowledgment: 

I Agree

8. Students, Introductory Participants, and Refresher Participants

Participant understands that certification training, introductory experiences, and refresher sessions have different objectives, limits, and supervision requirements.

Introductory experiences and refresher sessions do not, by themselves, confer a scuba certification. Enrollment in a certification course does not guarantee certification; applicable knowledge, skills, and other requirements must be met.

Participant agrees to remain within the boundaries and supervision requirements established for the program, follow instructions, and promptly report confusion, discomfort, distress, breathing-gas concerns, or equipment problems.

Participant will not enter the water or undertake a skill or dive beyond the instructor’s authorization.

Participant acknowledgment:

I Agree

9. Equipment Use

Participant agrees to use equipment only as instructed and within the limits of training and experience.

Participant will perform the equipment checks appropriate to the program and Participant’s training, seek assistance when unfamiliar with equipment, and promptly report missing, damaged, malfunctioning, or improperly fitting equipment. Participant will not knowingly continue using unsafe equipment.

Participant understands that personal, rented, or provided equipment can malfunction or fail. The assumption of risk and release in this agreement apply to equipment-related claims within their stated limits.

Participant checks do not replace inspection, maintenance, instruction, or other duties imposed on equipment providers or professionals by applicable law or standards.

Participant acknowledgment: 

I Agree

10. Premises and Facility Use

Activities may occur on private or public property, including a residential pool, pool deck, yard, walkway, villa, resort, dock, boat ramp, beach, or rocky shoreline.

Participant understands that these locations may contain wet, slippery, uneven, submerged, or unfamiliar surfaces. Participant agrees to exercise reasonable care, use appropriate footwear where applicable, and follow posted rules and verbal instructions.

Participant will use pools and other facilities only as authorized. Being part of a group trip does not mean that a lifeguard, instructor, or guide is continuously supervising recreational swimming or other free-time activities.

Participant is responsible for securing personal belongings. Property-loss claims are subject to the limits and exclusions stated in this agreement.

Participant acknowledgment: 

I Agree

11. Group Travel and Independent Providers

Company may arrange services supplied by independent businesses, including dive operators, boat operators, airlines, ground transportation providers, accommodations, excursion operators, and massage or wellness providers.

For services supplied by independent providers, Company’s role is arranging or coordinating those services. Any instruction, guiding, transportation, or other services directly provided by Company are distinct from services supplied by an independent provider.

Participant understands that Company does not control every aspect of an independent provider’s operations and cannot guarantee its performance or safety.

Participant agrees to follow applicable provider rules and complete any separate documentation required by that provider. An independent provider is not automatically a Released Party merely because Company arranges its services.

The assumption of risk and release provisions apply to claims against the Released Parties arising from travel arrangements and independent-provider services, including claims alleging Company’s ordinary negligence, only to the extent permitted by applicable law.

Participant acknowledgment: 

I Agree

12. Emergency Assistance

If Participant is injured, ill, incapacitated, or otherwise unable to make or communicate decisions, Participant authorizes Company to seek emergency assistance, first aid, rescue, transportation, or medical evaluation on Participant’s behalf.

Participant understands that assistance may be delayed or unavailable and that Company does not guarantee a particular medical outcome.

Participant remains responsible for emergency, medical, evacuation, and related expenses to the extent otherwise legally responsible. This section does not determine fault or eliminate claims that cannot lawfully be waived.

Participant acknowledgment: 

I Agree

13. Photos, Video, and Promotional Use

By signing this agreement, Participant authorizes Southern Utah Scuba LLC, doing business as Coral Escapes, to use photographs and video recordings depicting Participant, taken during the Activities, for Company’s marketing, promotional, and training purposes, including its website, social media, and printed materials, without compensation.

Participant may decline this permission by notifying Company in writing before participating. Declining media permission does not affect eligibility to participate. Participant may also withdraw permission for future use by notifying Company in writing. Upon receiving that notice, Company will stop making new promotional uses of media depicting Participant and remove such media from Company-controlled online promotional content within a reasonable time. Previously distributed printed materials and third-party copies may remain in circulation.

For a minor Participant, this authorization must be given by the parent or legal guardian signing this agreement.

Participant acknowledgment: 

I Agree

14. Governing Law and Severability

This agreement is intended to be governed by Utah law, except where applicable law requires otherwise.

If a provision is found unenforceable, the remaining provisions will continue in effect to the extent permitted by law.

No provision is intended to waive rights or impose obligations that applicable law does not allow.

Participant acknowledgment: 

I Agree


15. Acknowledgement 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) 

 October 22, 2026 

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
Diver Medical Questionnaire (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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 (Only fill out if you have not completed a medical form for us within the past 12 months, or if any health conditions have changed)

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. 

I am not engaging in scuba diving or free diving activities on this trip*
Agree (I will skip the medical questionnaire below and the pre-selected answers below will be disregarded).
Request to Use Existing Medical Documentation AND Skip Quiestionnaire: I confirm that I provided Southern Utah Scuba LLC, doing business as Coral Escapes, with a completed diver medical questionnaire within the past 12 months and any physician approval required by that questionnaire. My previous answers remain accurate. No change in my health, symptoms, injuries, illnesses, or medications would change those answers. I request that Company use my existing medical documentation for this trip, subject to verification and any applicable operator, training-agency, or insurance requirements. I understand that this confirmation does not extend the validity of my previous questionnaire or physician approval. If my documentation is unavailable, expired, or otherwise unacceptable, or my answers have changed, I must complete an updated questionnaire and obtain any required physician approval before diving.*
No (must fill out questionnaire below)
Yes (skip questionnaire below and we will disregard the pre-selected answers below)
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 questions 1-10 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 (Diver Medical Participant Questionnaire with it's attached Medical Examiner'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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