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Diver Medical Participant Questionnaire

Diver Medical | Participant Questionnaire

Please read this document thoroughly. Any scuba diving related activity REQUIRES this form to be filled out. Failure to follow it's instructions may result in any diving activities being delayed. We will NOT allow any student to dive without this form being completed.

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.

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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.


Full Name *

Birthdate: *
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes - Go to box A
No
2. I am over 45 years of age. *
Yes - Go to box B
No
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. *
Yes*
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses. *
Yes - Go to box C
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. *
Yes*
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. *
Yes - Go to box D
No
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. *
Yes - Go to box E
No
8. I have had back problems, hernia, ulcers, or diabetes. *
Yes - Go to box F
No
9. I have had stomach or intestine problems, including recent diarrhea. *
Yes - Go to box G
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).
Yes*
No
STOP | PLEASE READ BEFORE PROCEEDING

If you answered NO to all 10 questions above, further medical evaluation is NOT required and you may continue to the bottom of this page to sign (skipping all additional "box" questions below). Please read and agree to the participant statement at the bottom of the page by signing it.

* If you answered YES to questions 1, 2, 4, or 6 - 9 you must fill out the box corresponding to your YES answer(s) below.

* If you answered YES to starred questions 3, 5 or 10 above, please read carefully. You must agree to the participant statement at the bottom of this page by signing it. You ARE REQUIRED take this document, in its entirety, (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Failure to do so may result in not being able to enter the water.

Diver Medical Participant Questionnaire (supplemental information)

This section is ONLY required to complete if you answered YES to any above question


BOX A – I HAVE/HAVE HAD:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
No
Yes

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

I currently smoke or inhale nicotine by other means. *
No
Yes
I have a high cholesterol level. *
No
Yes
I have high blood pressure. *
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

BOX C – I HAVE/HAVE HAD:

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

BOX D – I HAVE/HAVE HAD:

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

BOX E – I HAVE/HAVE HAD:

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

BOX F – I HAVE/HAVE HAD:

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

BOX G – I HAVE HAD:

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

PLEASE READ

* If you answered YES to any questions in the BOXES in the above supplemental section, please read carefully. You ARE REQUIRED take this document, in its entirety, (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval. Failure to do so may result in not being able to enter the water. Once cleared by a physician, you must agree to the participant statement at the bottom of this page by signing it. 

Diver Medical | Medical Examiner’s Evaluation Form

Participant Name: ______________________________________  

Birthdate: ________________________

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas relevant to your patient as part of your evaluation.

Evaluation Result:

Approved – I find no conditions that I consider incompatible with recreational scuba diving or freediving.

Not approved – I find conditions that I consider incompatible with recreational scuba diving or freediving.

 

______________________________________________________

Signature of certified medical doctor or other legally certified medical provider           

_________________________________

Date (dd/mm/yyyy): 

Medical Examiner’s Name (print): _________________________________________

Clinical Degrees/Credentials: ____________________________________________

Clinic/Hospital: _____________________________________________________

Address: __________________________________________________________

Phone: _______________________  Email:______________________________

Physician/Clinic Stamp below (optional):

 


 ____________________________

 

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 Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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