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MEDICAL STATEMENT
Participant record (Confidential Information)
Please read carefully before slgnlng.
This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered
by (Instructor) _______________________________________________________________________
and (Facilitiy) ________________________________________________________________________
located in the city of ________________________________ state/province of _____________________
Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have
this Statement signed by a parent or guardian.
Diving Is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks.
To scuba dive safely., you should 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 coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization white scuba diving. Improper use of scuba equipment can result In serious Injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.
If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing.
Divers Medical Questionnaire.
To the Participant:
The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. 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 must seek the advice of your physician prior to engaging in dive activities.
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 any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.
_____Could you be pregnant, or are you attempting to become pregnant?
_____ Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)
_____ Are you over 45 years of age and can answer YES to one or more of the following?
- currently smoke a pipe, cigars or cigarettes
- have a high cholesterol level
- have a family history of heart attack or stroke
- are currently receiving medical care
- high blood pressure
- diabetes mellitus, even if controlled by diet alone
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)?
_____ Other chest disease or chest surgery?
_____ Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
_____ Epilepsy, seizures, convulsions or take medications to prevent them?
_____Recurring complicated migraine headaches or take medications to prevent them?
_____ Blackouts or fainting (full/partial loss of consciousness)?
_____ Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?
_____ Dysentery or dehydration requiring medical intervention?
_____Any dive accidents or decompression sickness?
_____ Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
_____ Head injury with loss of consciousness in the past five years?
_____Recurrent back problems?
_____ Back or spinal surgery?
_____ Diabetes?
_____ Back, arm or leg problems following surgery, injury or fracture?
_____ High blood pressure or take medicine to control blood pressure?
_____ Heart disease?
_____ Heart attack?
_____ Angina, heart surgery or blood vessel surgery?
_____ Sinus surgery?
_____ Ear disease or surgery, hearing loss or problems with balance?
_____ Recurrent ear problems?
_____ Bleeding or other blood disorders?
_____ Hemia?
_____ Ulcers or ulcer surgery ?
_____ A colostomy or ileostomy?
_____ Recreational drug use or treatment for, or alcoholism in the past five years?
The Information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.
__________________________ _____________ ___________________________ _____________
Sgnature Date Signature of Parent or Guardian Date
STUDENT
Please print legibly.
First Name_____________________Initial _______________Last Name_______________________________
Birth Date (day/month/year) ________________________ Age__________
Mailing Address_____________________________________________________________________________
City ______________________________ State/Province/Region_______________________________________
Country________________________________________ Zip/Postal Code _______________________________
Home Phone { ) ____________________________Business Phone ( )_________________________
Email __________________________________________FAX_________________________________________
Name and address of your family physician
Physician ______________________________________Clinic/Hospital_________________________________
Address____________________________________________________________________________________
Date of last physical examination____________________
Name of examiner ________________________________Clinic/Hospital Address ___________________________
Phone ( )_______________________________ Email __________________________________________
Were you ever required to have a physical for diving? ______(Yes or No ) If so, when?___________________________
PHYSICIAN
This person applying for training or is presently certified to engage in scuba (self-contained underwater breathing apparatus) diving. Your opinion of the applicant's medical fitness for scuba diving is requested. There are guidelines attached for your information and reference.
Physician's Impression
__ I find no medical conditions that I consider incompatible with diving.
__ I am unable to recommend this Individual for diving.
Remarks ______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________ ____________________________
Physician's Signature or Legal Representative of Medical Practitioner Date (Day/Month/Year)
Physician __________________________________Clinic/Hospital _________________________________________
Address __________________________________________________________________________________________
Phone ( ) ____________________________ Email _______________________________________________
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