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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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
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DATE: (mm/dd/yyyy) *
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