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2410 Milwaukee Street

Delafield, WI 53018

262-646-8283

dive@stillwaterdiving.com

 

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 fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/ or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

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

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

Please contact Stillwater Diving if you would prefer a paper version of this waiver


1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
No
Yes, Go to box A
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.
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 moths that limits my physical activity/exercise.
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.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.
NO, TO ALL THE ABOVE
2. I am over 45 years of age. *
No
Yes , Go to Box B
BOX B - I AM OVER 45 YEARS OF AGE AND: *
I currently smoke or inhale nicotine by other means
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
NO, TO ALL THE ABOVE
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes**
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes, Go to box C
BOX C - I HAVE/HAVE HAD: *
Sinus surgery in the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.
NO, TO ALL THE ABOVE
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. *
No
Yes**
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. *
No
Yes, Go to box D
BOX D - I HAVE/HAVE HAD *
Head injury with loss of consciousness within the last 5 years.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.
NO, TO ALL THE ABOVE
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability. *
No
Yes, Go to box E
BOX E - I HAVE/HAVE HAD: *
Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.
NO, TO ALL THE ABOVE
8. I have had back problems, hernia, ulcers, or diabetes. *
No
Yes, Go to box F
BOX F - I HAVE/HAVE HAD: *
Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia the limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
NO, TO ALL THE ABOVE
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes, go to box G
BOX G - I HAVE HAD: *
Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
NO, TO ALL THE ABOVE
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes**

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

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. 

** If you answered YES to question 3, 5, 10 OR to any of the questions in BOX A-G, please read and agree to statement above by signing and dating it, downloading/printing this form AND the Physician's Evaluation Form. Give this questionnaire and Physicians Evaluation Form to your physician for a medical evaluation. Participation in a diving course requires your physician's approval. 



If you need a Physician's Evaluation Form

Go to www.stillwaterdiving.com under Quick Links at the bottom of the page. Click on Physician's Evaluation Form.

You will also have access to the paper version of the Medical Statement. 

Issues?  Contact Stillwater Diving






DATE: (mm/dd/yyyy) *
First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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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