Heart disease, diabetes, high cholesterol. 15. Is there a family history of diabetes? 34. Is there a family history of asthma? …
APPENDIX 3
DIVING MEDICAL HISTORY FORM
To Be Completed By Applicant-Diver
Name ______________________________________ Sex ____ Age ___ Wt___ Ht
___
Sponsor ____________________________________________ Date ___/___/___
Dept/Project/Program/School, etc
Mo/Day/Yr
TO THE APPLICANT:
Scuba diving makes considerable demands on you, both physically and
mentally Diving with certain medical conditions may be asking for trouble
not only for yourself, but also to anyone coming to your aid if you get
into difficulty in the water Therefore, it is prudent to meet certain
medical and physical requirements before beginning a diving or training
program
Your answers to the questions are as important, in determining your
fitness as your physical examination Obviously, you should give accurate
information or the medical screening procedure becomes useless
This form shall be kept confidential If you believe any question
amounts to invasion of your privacy, you may elect to omit an answer,
provided that you shall subsequently discuss that matter with your own
physician and he/she must then indicate,
in writing, that you have done so
and that no health hazard exists
Should your answers indicate a condition, which might make diving
hazardous, you will be asked to review the matter with your physician In
such instances, his/her written authorization will be required in order for
further consideration to be given to your application If your physician
concludes that diving would involve undue risk for you, remember that
he/she is concerned only with your well-being and safety Please respect
the advice and the intent of this medical history form
| |Have you ever had or do you presently have any of the |Yes |No |Comments |
| |following? | | | |
|1 |Trouble with your ears, including ruptured eardrum, | | | |
| |difficulty clearing your ears, or surgery | | | |
|2 |Trouble with dizziness | | | |
|3 |Eye surgery | | | |
|4 |Depression, anxiety, claustrophobia, etc | | | |
|5 |Substance abuse, including alcohol | |
| |
|6 |Loss of consciousness | | | |
|7 |Epilepsy or other seizures, convulsions or fits | | | |
|8 |Stroke or a fixed neurological deficit | | | |
|9 |Recurring neurologic disorders, including transient | | | |
| |ischemic attacks | | | |
|10|Aneurysms or bleeding in the brain | | | |
|11|Decompression sickness or embolism | | | |
|12|Head injury | | | |
|13|Disorders of the blood, or easy bleeding | | | |
|14|Heart disease, diabetes, high cholesterol | | | |
|15|Anatomical heart abnormalities including patent foramen| | | |
| |ovale, valve problems, etc | | | |
|16|Heart rhythm problems | | | |
|17|Need for a pacemaker | | | |
|18|Difficulty with exercise
| | | |
|19|High blood pressure | | | |
|20|Collapsed lung | | | |
|21|Asthma | | | |
|22|Other lung disease | | | |
|23|Diabetes mellitus | | | |
|24|Pregnancy | | | |
|25 |Surgery If yes explain below | | | |
|26|Hospitalizations If yes explain below | | | |
|27|Do you take any medications? If yes list below | | | |
|28|Do you have any allergies to medications, foods, | | | |
| |environmentals? If yes explain below | | | |
|29|Do you smoke? | | | |
|30|Do you drink alcoholic beverages? | | | |
|31|Is there a family history of high cholesterol? | | | |
|32|Is there a
family history of heart disease or stroke? | | | |
|33|Is there a family history of diabetes? | | | |
|34|Is there a family history of asthma? | | | |
Please explain any yes answers to the above questions
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_
I certify that the above answers and information represent an accurate and
complete description of my medical history
Signature Date
Source:tcoek12.org
