LICENSED SKYDIVER SELF-DECLARATION OF FITNESS TO SKYDIVE
Skydiving (sport parachuting) is a risk sport where there is always a small but definite risk of death, injury or worsening of a pre-existing medical condition. This form is designed to help you identify whether you may be at greater than normal risk and may need to take qualified medical advice before jumping. If you can answer “True” after each of the following statements, you are allowed to sign the declaration and to continue to skydive without further advice. If you are in any doubt about your ability to sign this form truthfully, please take qualified medical advice (normally your GP or a specialist treating you). Skydiving instructors are not able to give medical advice. If you are unable to complete the declaration, it does not necessarily mean that you cannot jump but you should first seek qualified medical advice and ask your doctor to confirm your fitness to jump using Form 115F.
I DECLARE AND CONFIRM:
I am in robust physical health and am able to exercise without restriction. I understand that being unfit, being overweight for my height or having frailty of aging will render me more prone to injury.
I am not receiving any regular repeat medication, whether tablets, liquids, injections, patches or inhalers (contraceptive medication can be ignored for the purposes of this section). I do not have a recurrent need to use painkillers. I have never received prolonged courses of steroids or high dose steroid treatment in the past.
I understand that poor vision will endanger not only myself but also other skydivers around me. My vision is good enough to read a car number plate (made after 2001) at 20 metres. If I need glasses or contact lenses to achieve this standard, I will always wear them when skydiving. To the best of my knowledge I do not have a restricted field of vision or tunnel vision. I understand that persons aged over 60 (or those over 40 who have a close relative with an eye condition called glaucoma) are at risk of losing field of vision without being aware of it, but that a free NHS eye test can detect this. To the best of my knowledge I am not colour blind and can easily distinguish between red and green lights, or if I do have this problem, I will always inform my current chief instructor.
I have no problems with hearing, or if I have such problems, I will ensure that my current chief instructor is fully aware of them.
I do not have joint, back, sciatic or neck problems and have not been prone to these in the past. I have never had fractured or broken bones. I have NEVER dislocated a shoulder. I have not had torn tendons, ligaments or cartilages. I do not have weakness of any limbs. I have not had partial or complete loss of any limbs. I do not have rheumatism, arthritis or arthrosis. OR I have had one of these conditions in the past and have already completed 100 further jumps since receiving qualified medical advice that the condition is healed or stabilised.
I do not have any form of heart disease. I have never had a heart attack, myocardial infarction, coronary disease, angina, ischaemic heart disease, heart valve problems, heart failure, irregular pulse, palpitations, chest pain on exercising, peripheral vascular disease, Hypertrophic Cardiomyopathy (HOCM), cardiac pacemaker. I do not have a family history of sudden death at an early age. I do not have raised blood pressure or hypertension. If over 40 years of age, I understand that blood pressure problems are often “silent” and painless at first and that I should have had a blood pressure check with a qualified professional within the last five years.
I do not have any form of lung disease and can exercise vigorously without wheeze or unusual breathlessness. I have not been diagnosed with asthma, emphysema, chronic bronchitis, Chronic Obstructive Pulmonary Disease, fibrotic lung disease, pulmonary embolism (clot on the lung), pneumothorax (collapsed lung), Cystic Fibrosis. I do not use inhalers. I have not had a chest infection or pneumonia within the last 3 months.
I do not have any form of colostomy, ileostomy, urostomy, catheter, PEG, reservoir or other drainage, collection, infusion, shunt or pump device. I do not have any surgical implants or artificial joints. OR I do have one of the aforementioned and have completed 100 jumps since receiving qualified medical advice that it is unlikely to be a significant problem when skydiving.
I have not had any surgical procedures within the last 3 months. I have not received an organ transplant. I do not suffer from anaemia.
I have never had a serious head injury or fractured skull. I do not have epilepsy or fits and have not suffered from recurrent giddiness, dizziness, faints, blackouts or loss of consciousness. I do not have Cerebral Palsy, Myositis, Muscular Dystrophy, Multiple Sclerosis, Parkinsons Disease or any other progressive disease of the brain or nervous system. I have never had a stroke, transient ischaemic attack (TIA) or Vertebro-basilar Insufficiency (VBI). I do not suffer from disabling headaches.
I do not have diabetes. I do not have any form of endocrine or hormonal disease or deficiency such as thyroid or adrenal problems. I have never been diagnosed with osteopenia or osteoporosis (reduced bone strength).
I do not have a history of drug or alcohol dependence.
I do not have anxiety, depression or post-traumatic stress disorder and have neither needed to see a doctor nor needed any treatment for any of these in the last 2 years. I have never been diagnosed as having psychosis, schizophrenia, manic-depressive psychosis, bipolar disease or any other serious mental illness. I do not have a history of self-harming behaviour or suicide attempts.
I do not have significant learning difficulties, behavioural problems, ADHD, mental impairment, Down’s Syndrome (Trisomy 21) or any other form of trisomy. I do not have any problems with my memory. I have not been diagnosed as suffering from dementia, Alzheimer’s Disease or significant cognitive impairment.
I do not have sinus or ear disease. I do not normally suffer from ear or sinus pain when flying or skydiving. I understand that colds or sore throats may make me temporarily unfit to skydive because they increase the risk of ear or sinus pain or damage.
I have not been diagnosed as having cancer in any form. I have not donated blood in the last 6 months, OR if I have donated within the last 6 months, I have had a subsequent blood test showing my blood count is still normal.
I am not on sick leave and am not currently certified as unfit for work. I do not receive any form of sickness benefit, disability benefit or attendance allowance. I have not received a terminal diagnosis. I am not waiting for the results of any tests or investigations. I am not under medical review for any problems
To the best of my knowledge, I am not pregnant.
I do not have any form of infectious disease such as hepatitis, HIV or tuberculosis, which could pose a risk to first aiders if I was seriously injured and needed resuscitating.
If my health status changes so that this declaration is no longer valid, I will stop skydiving until I have received qualified medical advice and certification.
I understand that the purpose of this declaration is to enhance my safety and that of others around me. I know that if I am unable to complete it truthfully, or do not understand any part of the form, I must postpone any skydiving until I have obtained qualified advice.
I have had enough time to read (or be read) this form. I have understood it or taken appropriate advice to enable me to understand it.
This form is valid for 3 years from the date of signature, provided there is no change in medical condition or injury.
