(1) My Diabetes is controlled by; c Insulin Injection c Oral (2) I have had no hospitalizations for a condition related to Diabetes in the last 12 months. …
Utila Community Clinic Clinica Comunal de
Utila
Utila, Bay Islands, Honduras, CA Tel: 504 425-3137 Email:
utilaclinic@yahoocom
Diabetic Diver Medical Questionnaire
Please complete the following by checking the appropriate box for each
question
1 My Diabetes is controlled by; Insulin Injection Oral Medication
Diet Exercise Check all that apply
My diabetes medications are;
Name ____________________ Dose ___________ Name
____________________ Dose ___________
2 I have had no hospitalizations for a condition related to Diabetes in
the last 12 months
True False Dont Know
3 I have had no episodes of hypoglycemia requiring hospitalisation,
loss of consciousness, seizure, treatment with Glucagon, or needed the
assistance of another person in the last 12 months
True False Dont Know
4 I am familiar of the dangers of hypoglycemia and I am aware of my
personal symptoms when approaching a hypoglycaemic state
True False Dont Know
5 My medical treatment regime has not been altered in the last
12
months
True False Dont Know
6 I have regular annual Diabetes check-ups
True False Dont Know
7 My Glycosylated Hemoglobin HbAlc is less than 9
True False Dont Know
8 There has been no evidence of Microalbuminuria or Proteinuriain my
recent medical test results
True False Dont Know
9 There has been no evidence of Retinopathy, Neuropathy, or Vascular
disease caused by Diabetes in my recent medical test results
True False Dont Know
10 My Doctor will agree that my Diabetes is well controlled
True False Dont Know
11 I carry and regularly use a portable Glucometer
True False Dont Know
12 In my Dive Kit I carry;
a Oral glucose tablets and tube of glucose paste, True
False Dont Know
b Glucometer and test strips with clear instructions on its use
True False Dont Know
13 My Dive Buddy knows I am a Diabetic Diver and how to deal with any
Diabetes problems I might experience
True False Dont Know
14 My Dive Buddy knows;
a the signs and symptoms of hypoglycemia, True False
Dont Know
b how to use my Glucometer, True False Dont Know
15 I will be responsible for obtaining a signed and completed
Physicians Report supplied by Utila Community Clinic from the
Physician or organisation in charge of my Diabetes care and
returning the completed report to the Utila Community Clinic
True False Dont Know
__________________________________
_____________________________ _____________
Full Name Signature Date
