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Diver Medical | Participant Questionnaire

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

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

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.

Name: Birthdate:

I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.

Yes - Go to box A

No
I am over 45 years of age.
Yes - Go to box B

No
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
I have had problems with my eyes, ears, or nasal passages/sinuses.
Yes - Go to box C

No
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
Yes*

No
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
Yes - Go to box D

No
I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.
Yes - Go to box E

No
I have had back problems, hernia, ulcers, or diabetes.
Yes - Go to box F

No
I have had stomach or intestine problems, including recent diarrhea.
Yes - Go to box G

No
I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).
Yes*

No

STOP | PLEASE READ BEFORE PROCEEDING

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

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

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

Diver Medical | Participant Questionnaire (supplemental information)

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

BOX A – I HAVE/HAVE HAD:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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 drug 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

PLEASE READ

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

Diver Medical | Medical Examiner’s Evaluation Form

Participant Name: ______________________________________
Birthdate: ________________________

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

Evaluation Result:

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

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

______________________________________________________
Signature of certified medical doctor or other legally certified medical provider

_________________________________
Date (dd/mm/yyyy)

Medical Examiner’s Name (print): _________________________________________

Clinical Degrees/Credentials: ____________________________________________

Clinic/Hospital: _____________________________________________________

Address: __________________________________________________________

Phone: _______________________ Email:______________________________

Physician/Clinic Stamp below (optional):

____________________________

Participant Statement:

I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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16 September 2023 15:30 EDT

Diver Medical | Participant Questionnaire Uploaded by Brian Mullins - dive@raleighscubadiving.com IP 64.96.81.18

13 November 2023 13:30 EDT

Amy Mullins - amy@raleighscubadiving.com added by Brian Mullins - dive@raleighscubadiving.com as a CC'd Recipient Ip: 2603:6080:c00:1700:e1e8:7fdc:7e13:dce0

16 November 2023 16:20 EDT

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22 November 2023 17:46 EDT

Amy Mullins - amy@raleighscubadiving.com added by Brian Mullins - dive@raleighscubadiving.com as a CC'd Recipient Ip: 2603:6080:c00:1700:c561:3749:9dd0:be41