Medical Statement ———————————— PARTICIPANT RECORD — CONFIDENTIAL INFORMATION —————————————
Please read carefully before g. This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by: (INSTRUCTOR) ___________________________________________ and (FACILITY) __________________________________________ located in the city of __________________________________ and state of _________________________________________. Read and discuss this statement prior to g it. You must complete this Medical Statement, which includes the medical-history section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent. Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there are dangers.
To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor and the Instructor before participation in this program. You will also need to learn from the Instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified Instructor to use it safely. If you have any additional questions regarding this Medical Statement or the Medical History section, review them with your Instructor before g.
Medical History
To the Participant: The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician. Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your Instructor will supply you with a medical statement and guidelines for recreational scuba diver’s physical examination to take to your physician. ____ Could you be pregnant, or are you attempting to become pregnant? ____ Are you presently taking presecription medications? (with the exception of birth control or anti-malarial) ____ Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars, or cigarettes • have a high cholesterol level • have a family history of heart attacks or strokes • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE… ____ Asthma, or wheezing with breathing, or wheezing with exercise? ____ Frequent or severe attacks of hayfever or allergy? ____ Frequent colds, sinusitis or bronchitis?
____ Any form of lung disease? ____ Pneumothorax (collapsed lung)? ____ Other chest disease or chest surgery? ____ Behavioral health, mental or psychological problems problems (panic attack, fear of closed or open spaces)? ____ Epilepsy, seizures, convulsions or take medications to prevent them? ____ Recurring migraine headaches or take medications to prevent them? ____ Blackouts or fainting (full/partial loss of consciousness)? ____ Frequent or severe suffering from motion sickness (seasick, carsick, etc.)? ____ Dysentery or dehydration requiring medical intervention? ____ Any dive accidents or decompression sickness? ____ Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
____ Head injury with loss of consciousness in the past five years? ____ Recurrent back problems? ____ Back or spinal surgery? ____ Diabetes? ____ Back, arm or leg problems following surgery, injury or fracture? ____ High blood pressure or take medication to control blood pressure? ____ Heart disease? ____ Heart attack? ____ Angina, heart surgery or blood vessel surgery? ____ Sinus surgery? ____ Ear disease or surgery, hearing loss or problems with balance? ____ Recurrent ear problems? ____ Bleeding or other blood disorders? ____ Hernia? ____ Ulcers or ulcer surgery? ____ A colostomy or ileostomy? ____ Recreational drug use or treatment for, or alcoholism in the past five years?
The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. __________________________________________________________________________________________________
_______________________
SIGNATURE
DATE
__________________________________________________________________________________________________
_______________________
SIGNATURES OF PARENTS OR GUARDIANS WHERE APPLICABLE
DATE
© 1993 CONCEPT SYSTEMS, INC. Rev. 3/02, 3/03
ADRO:SSI:EDU:DIVER:STUDENT:MEDICAL:“Medical Exam 3/03”:ART FILE #1162-D
Reorder #1512RSTC
Student
(Please print legibly)
Name __________________________________________ Birth Date ____________ Age ______ First
Initial
Last
Mailing Address _________________________________________________________________________ ________________________________________________________________________________________ City _________________________________ State/Province _________________________________ Country __________________________________________ Zip/Postal Code _________________
) ( ) Home Phone (_________________________ Business Phone ________________________________ Telex _______________________________ FAX ______________________________________ Name and address of your family or primary care physician: Physician ____________________________ Clinic/Hospital _________________________________
) Address _____________________________________ Phone ( _______________________________ Date of last physical examination __________________________________________________________ Name of examiner _____________________ Clinic/Hospital _________________________________
) Address _____________________________________ Phone ( _______________________________ Were you ever required to have a physical for diving?
Yes
No If so, when? _____________
Physician This person is an applicant for training or is presently certified to engage in scuba (self contained underwater breathing apparatus) diving. Your opinion of the applicant’s medical fitness for scuba diving is requested. Please review Guidelines for Recreational Scuba Diver’s Physical Examination.
Physician’s Impression: I find no medical conditions that I consider incompatible with diving. I am unable to recommend this individual for diving. Remarks _______________________________________________________________________________ I have reviewed Guidelines for Recreational Scuba Diver’s Physical Examination. ____________________________________________________________________________, M.D. Physician’s Signature
Date ______________
Physician ____________________________ Clinic/Hospital _________________________________
) Address ______________________________________________ Phone (______________________
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