Antigua SCUBA Diving - medical form

Scuba Diving Medical Questionnaire

Scuba 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 head 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 participating in this program.

The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational scuba diving. 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 should 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 you answer YES to any question, you can contact us to discuss the issue. The prudent thing to do is to first consult with a physician prior to participating in scuba diving. Go to doctor's form and print out

MEDICAL HISTORY

____ Could you be pregnant or are you attempting to become pregnant?

____ Do you regularly take prescription or nonprescription medications?
(with the exception of birth control)

____ Are you over 45 years of age.

_____ Do you have have one or more of the following?

• currently smoke a pipe, cigars or cigarettes
•have a high cholesterol level
•have a family history or heart attacks or strokes

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)?

____ History of chest surgery?

____ Claustrophobia or agoraphobia
(fear of closed or open spaces)?

____ Behavioral health problems?

____ Epilepsy, seizures, convulsions or take medications to prevent them?

____ Recurring migraine headaches or take medications to prevent them?

____ History of blackouts or fainting (full /partial loss of consciousness)?

____ Do you suffer from motion sickness (seasick, carsick, etc)?

____ History of diving accidents or decompression sickness?

___ History of recurrent back problems?

____ History of back surgery?

____ History of diabetes?

____ History of back, arm or leg problems following surgery, injury or fracture?

____ Inability to perform moderate exercise.
example: walking one mile within 12 minutes?

____ History of high blood pressure or take medication to control blood pressure?

____ History of any heart disease?

____ History of heart attacks?

____ Angina or head surpery or blood vessel surgery?

____ History of ear or sinus surgery?

___ History of ear disease, hearing loss or problems with balance?

____ History of problems equalizing (popping) ears with airplane or mountain travel?

____ History of bleeding or other blood disorders?

____ History of any type of hernia?

____ History of ulcers or ulcer surgery?

____ History of colostomy?

____ History of drug or alcohol abuse.

This information I have provided about my medical history is accurate to the best of my knowledge

Participant _______________________________________________

Signature ________________________________________________

Date_________________________________________________

Parent/Guardian:

Your Name _______________________________________________

Signature ________________________________________________

Date_________________________________________________