The basis for this project is to try and assess whether diving and diabetes is actually safe. to provide evidence that divers with diabetes can scuba dive. …
DIVING AND DIABETES
Section A To be completed by the diver
The basis for this project is to try and assess whether diving and diabetes
is actually safe Many people worldwide believe it is not This study is
the only one of its kind gathering these types of data We appreciate you
may have a reluctance to complete some sections of this questionnaire
However we would encourage you to complete each section to the best of your
ability It is vital we have a better understanding of how you dive and
any problems you may encounter, which may or may not be related to
diabetes The long-term aim of this study is to provide evidence that
divers with diabetes can scuba dive All the answers which you provide
will be treated in the strictest confidence and no references to any named
individuals will occur
GENERAL INFORMATION: name and address details IN CAPITAL LETTERS PLEASE
|Name of | |
|diabetic | |
|Address of | |
|diabetic |
|
| | |
| | |
|Home phone/fax | |
|number | |
|Work phone/fax | |
|number | |
|Email address | |
Medical personnel: name and address details IN CAPITAL LETTERS PLEASE
|Name of physician in charge| |
| | |
|Address of physician in | |
|charge | |
| | |
| | |
|Phone/fax of physician in | |
|charge | |
|Name of general
| |
|practitioner | |
|Address of general | |
|practitioner | |
| | |
| | |
|Phone/fax of general | |
|practitioner | |
|Name of medical referee | |
|Address of medical referee | |
| | |
| | |
|Phone/fax of medical | |
|referee | |
GENERAL INFORMATION cont Please circle or tick each answer as appropriate
|Gender |Height |Affiliation |
| |cm |BSAC SAA SSA Other
|
|M F | | |
|Date of birth |Weight |Membership |
| |kg | |
|/ / | |Number branch |
|DD MM | | |
|YY | | |
| | |
|Are you new to the sport Yes |Please circle a all the year round |
|No |or b only in the summer |
| | |
|If yes go to question 5 |for the response below as appropriate: |
| | |
| |Do you dive: |
| |UK a b |
| |Abroad a b |
DDRC 2002
DIVING INFORMATION
|1 Year of first dive |4b If you have been an |4c What bottom |
| |active diver in the last 12 |mix gas do you |
| |months please tell us how |mainly use? |
| |many dives at each depth |circle as |
| |range |appropriate |
| | | |
| | |Air |
|2 How many dives have| | |
|you made in your |0 - 10 metres | |
|diving career | | |
| | 11 - 20 metres | Nitrox |
|3 Date of last dive | | |
|// |21 - 30 metres |Trimix |
|DD MM YY | | |
| | | |
|4 How many dives have|More than 30 metres: | |
|you made in the last | |
|
|12 months | | |
| |Number of dives with a | |
| |compulsory deco stop: | |
| | | |
|4a What is the | | |
|maximum depth you have| | |
|dived in the last 12 | | |
|months | | |
| | | |
|metres | | |
HEALTH INFORMATION - Please circle or tick each answer as appropriate
| | |
|5 Have you been admitted to hospital for a diabetic |Yes No |
|condition in the last 12 months? If yes, please tell us| |
|about it on page 5 | |
| | |
|6 Have you experienced any
episodes of hypoglycaemia in|Yes No |
|the last 12 months and in what circumstances did these | |
|occur If yes please tell us about it on page 5 | |
| | |
|7 Have you had an annual checkup at the diabetic clinic|Yes No |
|involving eyes, nervous system, kidneys and glycosylated| |
|haemoglobin or fructosamine level | |
| |Name/Make |
|8 What portable glucometer do you use and how often do | |
|you calibrate it | |
| |Calibration |
| | |
|9 Who undertakes the majority of your diabetic care |Hospital |
| |GP |
| | |
| |Always |
|10 Do you check blood glucose pre and post dive
|Sometimes |
| |Never |
| | |
|11 Do you eat or drink as appropriate pre dive |Yes No |
| | |
|12 Have you had any incidents due to low blood sugar in|Yes No |
|the last year | |
|If yes please explain the circumstances and the outcome | |
|on page 5 | |
| | |
|13 Please give the year when was diabetes first | |
|diagnosed and under what circumstance, you can give | |
|details on page 5 | |
| | |
|14 Do you smoke cigarettes |Yes No |
| | |
|14a If yes please indicate how many a day |How many |
|
| |
|15 Do you regularly consume alcohol |Yes No |
| | |
|15a If yes please indicate you average weekly |How much |
|consumption | |
| | |
|One unit half pint of beer, lager or cider, or one | |
|measure of spirits or vermouth, | |
|or one glass of wine or sherry | |
| | |
|16 Women only to answer this question Does the |Yes No |
|control of your diabetes differ in relation to your | |
|menstrual cycle? If yes please tell us how on page 5 | |
| | |
|17 Do you take fluids before you dive |Yes No |
| | |
|
|
|We recommend you carry the following in your dive kit |
|aOral glucose tablets or a tube of glucose paste |
|bEmergency intramuscular injection of glucagon |
|cGlucose oxidise sticks together with the necessary glucometer kit and|
|CLEAR instructions for the use of such a kit |
| |
|18 Do you carry all or any of the above with you to the dive site or |
|on the boat, |
|please indicate by putting a circle round your answer |
|Always a b c |
| |
|Sometimes a b c |
| |
|Never a b c |
| | |
|19 Is there always someone in the dive party
who is |Yes No |
|able to use and administer the glucose tablets and | |
|intramuscular injection of glucagon, should this be | |
|required | |
| | |
|20 What do you carry in the form of glucose | |
|underwater - please define eg Mars Bar, Hypostop | |
| | |
|21 Do you know how to use glucose paste underwater |Yes No |
| | |
| |In the last 6 |
|21a If yes when did you last practice |months |
| | |
| |6 to 12 months |
| |ago |
| | |
| |More than 12
|
| |months age |
| | |
|21b If you have practiced using glucose paste |Successful |
|underwater, how successful was the exercise |Not successful |
| | |
|22 Have you or your buddy experienced any problems |Yes No |
|of any nature during the course of the diving in the | |
|last 12 months? If yes please give us details on | |
|page 5 | |
| | |
|23 Do you consider that your diabetes has had any |Yes No |
|adverse effect on you or your buddys diving during | |
|the last 12 months? If yes please give details on | |
|page 5 | |
| | |
|24 Do you dive with the same buddy all the time |Yes No |
|
| |
| |Very well |
|25 How well informed is your buddy regular or |Adequately |
|otherwise about your condition |Not well |
| | |
| |Very well |
|26 How well informed is your club about your |Adequately |
|condition |Not well |
| |In the last 6 |
|26a When did you last give a lecture to your club on|months |
|diabetes | |
| |6 to 12 months |
| |ago |
| | |
| |More than 12 |
| |months ago |
Section B To be completed by the
Physician-in-charge
LONG-TERM DIABETIC CONTROL - Please circle or tick each answer as
appropriate
| | |
|1 What is the diabetics medication regime | |
| | |
| | |
| | |
| | |
| |In the last 6 months |
|2 When was the medication last changed |6 to 12 months ago |
| |More than 12 months ago |
| | |
|3 Have any episodes of hypoglycaemia |Yes No |
|occurred in the last year and in what | |
|circumstances did these occur? | |
| |In the last 6 months |
| |6 to 12 months ago
|
|If yes please indicate when, and tell us | |
|about it on page 5 | |
| | |
|4 Has the diabetic been hospitalized within|Yes No |
|the last year for any condition relating to | |
|diabetes? |In the last 6 months |
| |6 to 12 months ago |
|If yes please indicate the date and tell us | |
|about it on a separate piece of paper | |
| | |
| | |
|5 What is the current HbA1c or fructosmine| Normal |
|level and please give the normal range for | |
|your readings | |
| |In the last 6 months |
| |6 to 12 months ago |
|5a When was the test
performed |More than 12 months ago |
| | |
|6 Is microalbuminuria present |Yes No |
| | |
| | |
|6a When was the test performed |In the last 6 months |
| |6 to 12 months ago |
| |More than 12 months ago |
| | |
|7 What degree of retinopathy is present |None Mild background |
| |Proliferative |
| | |
| | |
|7a When was this last checked |In the last 6 months |
| |6 to 12 months ago |
| |More than 12 months ago |
| |
|
|7b Has this person ever had laser treatment|Yes No |
|to the eyes | |
| | |
|8 Is any degree of sensory or autonomic |Yes No |
|neuropathy present a check for the latter | |
|may be made by looking for R-R variation in | |
|the ECG as a Valsalva manoeuvre is | |
|performed; if there is no variation then a |In the last 6 months |
|degree of autonomic neuropathy may be |6 to 12 months ago |
|present |More than 12 months ago |
| | |
|8a When was this last checked | |
| | |
|9 Is any degree of coronary, vascular or |Yes No |
|microvascular disease present | |
| | |
|10
Do you consider this persons level of |Yes No |
|diabetic control to be satisfactory | |
| | |
|11 Do you consider that this person is |Yes No |
|mentally and physically fit to undertake a | |
|sport that involves a degree of stress and | |
|exertion | |
NOTES TO THE PHYSICIAN-IN-CHARGE
Question 6 Is microalbuminuria present? When was the test performed?
It is recommended this test be performed or the application may be
rejected References given on page 5 illustrate the cost-effectiveness of
this screening test
Question 9 Is any degree of coronary, vascular or microvascular disease
present? If possible an exercise ECG is recommended for diabetic divers
over the age of 50
PLEASE BE KIND ENOUGH TO COMPLETE PAGE 5 - THANK YOU
Your cooperation in completing this form is greatly appreciated by the
UK Sport Diving Medical Committee
|
|
|Please ensure you obtain all the required signatures - Thank you |
|Signature of the physician in |Name print |
|charge | |
| | |
|Date |Hospital/practice stamp |
|Signature of the medical referee |Name print |
| | |
|Date | |
|The diabetics signature |Name print |
| | |
|Signature of Branch DO |Name print |
| | |
| | |
References
1 Viberti GC, Jarrett RJ, Mahmud U, Microalbuminuria as a predictor
of clinical nephropathy in insulin-dependent diabetes mellitus,
Lancet 119821430-2
2
Mogensen CE, Microalbuminuria predicts clinical proteinuria and early
mortality in maturity onset diabetes, N Eng J Med 3101984356-60
3 Jarrett RJ, Viberti GC, Argyropoulos A, et al Microalbuminuria
predicts mortality in non insulin-dependent diabetics, Diabetic Med
1198417-19
4 Microalbuminuria Collaborative Study Group Risk factors for the
development of microalbuminuria in insulin dependent diabetic
patients: a cohort study, Brit Med J 30619931235-9
5 Bakris GL, Microalbuminuria: what is it? Why is it important? What
should be done about it? J Clin Hypertension 3200199-102
INSTRUCTIONS TO THE DIABETIC DIVER
Please also complete the general health diving questionnaire UK Sport
Diver Medical Form attached to this questionnaire - you complete
section A and your Dr completes section B
1 Please allow adequate time before you require your medical
certification renewal for signatures to be obtained and for Dr Edge
to reply to you
2 Answer all the questions in section A to the best of your ability by
writing answers clearly or circling or ticking the
appropriate
responses
3 Take this whole form to your physician in charge for him/her to
complete and sign section B
4 Obtain the signatures of your diving medical referee see point 6 and
also your Branch DO if you dive in a club in which the Diving Officer
is responsible for the diving undertaken
5 Send the whole form back to Dr Chris Edge, The Stone Barn, Gravel
Lane, Drayton, Nr Abingdon, Oxon OX14 4HY, United Kingdom
6 If you have any queries, then either telephone your nearest diving
medical referee telephone BSAC HQ on 0151 350 6200 for a list or
point your web browser at wwwbsacorg and follow the hyperlinks or
contact Dr Chris Edge on tel 01235 529888, fax 08700 525414, email
cjedge@diverdemoncouk
In due course Dr Edge or Dr Bryson will send you section C that you should
then give to your Branch diving officer This becomes part of your
Certificate of Fitness to Dive
SPACE FOR FURTHER DETAIL AS REQUIRED
DDRC 2002
Source:uksdmc.co.uk
