Loading...

Open Water Scuba Diver

Registration & Agreement

PLEASE READ CAREFULLY AS WE WILL CITE THIS AGREEMENT.

Course Agreement

1. I will attend the required 1 classroom session(s), the required 1 group pool session, and 4 group ocean dives of the Open Water SCUBA Diver course costing 299.00.

2. The following SCUBA quality equipment is necessary: Mask, snorkel, fins, boots, wetsuit, regulator, BCD, computer, slate, signaling device, and logbook. Basic student kit must be purchased from SCUBA Network.  All other items may be borrowed, rented or purchased. Equipment bench test inspections cost $25 (for those that have bought or borrowed equipment not from SCUBA Network). Any equipment borrowed or rented must be taken from and returned to the SCUBA Network location from which it was borrowed or rented before and after class.

I understand that Mask, Snorkel and Wetsuit may not be borrowed.

3. 4 Ocean Dives are included over 2 days. Group beach dives can be completed on Saturdays. Group boat dives can be completed on Sundays. Boat tickets for training dives are $99.50 for local boats and $125 for the Keys. If an additional boat session is required, I understand I will have to pay for an additional boat ticket and the training session of $35. I understand that boat ticket prices are set by the charter and are subject to change.

4. Important information is included in every class, pool and open water session. You must attend every session or your training will be incomplete. You must successfully complete a final evaluation in order to be certified as a scuba diver. The instructor, at their discretion, must make final judgment of competency to be a safe diver to earn the certification. Additional training may be required at an additional cost if the training requirements aren’t met. 

5. I understand that there is a $129.95 non-refundable eLearning course included in the price of this course. I also understand that if I cancel for any reason after 10 days or if the eLearning code is activated, this eLearning is not refundable. Additionally, if I cancel less than 5 days before the first session, 50% of the course cost is non-refundable. After the first session, OR if more than 90 days has passed from the original purchase date, there will be no refunds on any course costs.

6. I understand that if I make any changes to my course schedule less than 5 days before the scheduled training date, it will cost $35 to schedule to another training session. 

7. It is important to move to each step of the diving course in a timely manner so the previous step is fresh in your mind. The classroom academic review must be completed within 3 months of sign-up date or it will expire. Pool sessions must be completed within 60 days of academic review. Open water dives must be completed within 60 days of the pool sessions. A $35 refresher will be required for those going beyond the 60 day period.

8. I understand that I have ONE YEAR to complete the entire training program from my first training date. If one year expires, I will have to repeat the entire course at an additional cost of $35 per training session in addition to any boat ticket costs.

9. For your safety and ours, SCUBA Network reserves the right to inspect all equipment you will be using in the pool or during open water dives PRIOR to starting any classes. At the sole discretion of SCUBA Network, any equipment deemed unsatisfactory or unfamiliar will not be allowed to be used. I understand that by not having equipment checked prior to the class sessions I may be turned away and be required to schedule an additional training session at additional cost. I understand that if I use personal equipment purchased outside of SCUBA Network and require assistance, I assume all risk of any damage to said equipment in the course of training.

I have read this agreement. I understand it. I agree to be bound by it. 

 

GENERAL LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK 

Directions: Please read carefully, fill in all blanks and initial each paragraph before signing at bottom. 

For (specify Course or Specialty at bottom of waiver) training program under sanction through SDI.

I hereby affirm that I have been advised and thoroughly informed of the inherent hazards of scuba diving activities

Further, I understand that diving with compressed air or oxygen enriched air (nitrox) involves certain inherent risks including decompression sickness, embolism, oxygen toxicity, inert gas narcosis, marine life injuries or other barotrauma/hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that the open water diving trips, which are necessary for training and certification, may be conducted at a site that is remote, either by time of distance or both, from such a recompression chamber. I still choose to proceed with such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site.  

 

I understand and agree that neither my Instructor(s)  the facility through which I received my Instruction,FLL SCUBA, Inc or Boca SCUBA Inc dba "Scuba Network," International Training and Scuba Diving International, nor the officers, directors, shareholders, affiliated companies, employees, agents, or assigns of the above listed entities and/or individuals, nor the authors of any materials including texts and tables expressly used for training and certification (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death, or other damages to me or my family, heirs, or assigns that may occur as a result of my participation in this diving class or as a result of the negligence of any party, including the Released Parties, whether passive or active. 

In consideration of being allowed to enroll in this course, I hereby personally assume all risks in connection with said course, for any harm, injury, or damage that may befall me while I am enrolled as a student of this course, including all risks connected therewith, whether foreseen or unforeseen. 

I further agree to save, defend, indemnify, and hold harmless said course and Released Parties from any claim or lawsuit by me, anyone purporting to act on my behalf, my family, estate, heirs or assigns, arising directly or indirectly out of my enrollment and participation in this course including both claims arising during the course or after I receive my certification even if such claims may be groundless, false or fraudulent. 

I also understand that diving activities are physically strenuous and that I will be exerting myself during this diving course, and that if I am injured as a result of heart attack, panic, hyperventilation, oxygen toxicity, inert gas narcosis, drowning, etc. that I expressly assume the risk of said injuries and that I will not hold the above listed individuals or companies responsible for the same, and I agree to defend, indemnify, and hold harmless said course and Released Parties for any such injuries incurred by me.  

I understand that these activities may place me deeper than I am able to safely execute a free (without breathing gas) ascent from.  

I understand that I may be required to furnish my own equipment and that I am responsible for its operating condition and maintenance.  

I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian.  

I understand that the terms herein are contractual and not a mere recital, and that I have signed this document of my own free act. Further that I understand and agree that, in the event that one or more of the provisions of this agreement, for any reason, is held by a court of competent jurisdiction to be invalid or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this agreement shall be construed as if such invalid, illegal or unenforceable provision or provisions had never been contained herein.  

IT IS THE INTENTION OF BY THIS INSTRUMENT TO EXEMPT AND RELEASE MY INSTRUCTORS ROBERT FOERSTER, JON LANDRESS, MEGHAN MUSSO, SHELBY BROWN, COLIN LEE, MELISSA WITT (AND OTHERS), THE FACILITY THROUGH WHICH I RECEIVED MY INSTRUCTION BOCA SCUBA, INC OR FLL SCUBA, INC, DBA "SCUBA NETWORK," THE TRAINING AGENCY SCUBA DIVING INTERNATIONAL AND INTERNATIONAL TRAINING AND SCUBA DIVING INTERNATIONAL, AND ALL OTHER RELATED ENTITIES AND RELEASED PARTIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, OR ARISING OUT OF, DIRECTLY OR INDIRECTLY, INCLUDING, BUT NOT LIMITED TO, THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF AND MY HEIRS.

This document is required for all courses and Specialties taught under sanction by Scuba Diving International. No alterations, changes, omissions or revisions may be made.

February 20, 2024

 

 

 

 

 

 

 

 

 

 

 

 


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Second Participant's Date of Birth*
Second Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Third Participant's Date of Birth*
Third Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Fourth Participant's Date of Birth*
Fourth Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Fifth Participant's Date of Birth*
Fifth Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Sixth Participant's Date of Birth*
Sixth Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Seventh Participant's Date of Birth*
Seventh Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Eighth Participant's Date of Birth*
Eighth Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Ninth Participant's Date of Birth*
Ninth Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Tenth Participant's Date of Birth*
Tenth Participant's Course

For Training Program:

Training program under sanction through SDI:*
ADVANCED ADVENTURE
ADVANCED BUOYANCY
ASSISTANT INSTRUCTOR
DEEP
DRIFT
DRY SUIT
DIVEMASTER
INSTRUCTOR DEVELOPMENT COURSE
MARINE ECOSYSTEMS AWARENESS
NAVIGATION
NIGHT
NITROX
OPEN WATER
REFRESHER
RESCUE
SOLO DIVER
UNDERWATER PHOTOGRAPHY
UNDERWATER VIDEOGRAPHY
WRECK

Shirt Size *

US Shoe Size (Specify Men's or Women's) *

Diver Medical | Participant Questionnaire

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

Directions

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

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

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
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 - Complete Box C Below
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 - Complete Box D Below
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 - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10 I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*
Yes
No

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G, please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (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.

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.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

Box B - I am over 45 years of age AND:

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

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

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*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact