Heart disease, diabetes, high cholesterol Diabetes mellitus. Pregnancy. Yes. No Is there a family history of diabetes? Is there a family history of asthma? …
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 your physical and emotional
condition Diving with particular defects amounts to asking for trouble
not only for yourself, but 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 more important, in many instances, in
determining your fitness than what the physician may see, hear or feel
when you are examined 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 Respect
the advice and the intent of this medical history form
| |Yes |No |Have you ever had or do you presently have |Comments |
| | | |any of the following? | |
| | | |Trouble with your ears, including ruptured | |
| | | |eardrum, difficulty clearing your ears, or | |
| | | |surgery | |
| | | |Trouble with dizziness | |
| | | |Eye surgery | |
| | |
|Depression, anxiety, claustrophobia, etc | |
| | | |Substance abuse, including alcohol | |
| | | |Loss of consciousness | |
| | | |Epilepsy or other seizures, convulsions or | |
| | | |fits | |
| | | |Stroke or a fixed neurological deficit | |
| | | |Recurring neurologic disorders, including | |
| | | |transient ischemic attacks | |
| | | |Aneurysms or bleeding in the brain | |
| | | |Decompression sickness or embolism | |
| | | |Head injury | |
| | | |Disorders of the blood, or easy bleeding | |
| | | |Heart disease, diabetes, high cholesterol | |
| | | |Anatomical heart abnormalities including | |
| | | |patent foramen ovale, valve problems, etc |
|
| | | |Heart rhythm problems | |
| | | |Need for a pacemaker | |
| | | |Difficulty with exercise | |
| | | |High blood pressure | |
| | | |Collapsed lung | |
| | | |Asthma | |
| | | |Other lung disease | |
| | | |Diabetes mellitus | |
| | | |Pregnancy | |
| |Yes |No |Have you ever had or do you presently have |Comments |
| | | |any of the following? | |
| | | |Surgery If yes explain below | |
| | | |Hospitalizations If yes explain below | |
| | | |Do you take any medications? If yes list | |
| | |
|below | |
| | | |Do you have any allergies to medications, | |
| | | |foods, environmentals? If yes explain below | |
| | | |Do you smoke? | |
| | | |Do you drink alcoholic beverages? | |
| | | |Is there a family history of high | |
| | | |cholesterol? | |
| | | |Is there a family history of heart disease or| |
| | | |stroke? | |
| | | |Is there a family history of diabetes? | |
| | | |Is there a family history of asthma? | |
Please explain any yes answers to the above questions
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___________________________________________________________________________
__________________________________________________
I certify that the above answers and information represent an accurate and
complete description of my medical history
Signature __________________________________________ Date
________________________
