Download Medical Evaluation Form.

Middletown Scuba
17 Dolson Avenue • Middletown, NY 10940
845-343-2858 • [email protected]
Medical Statement
———————————— PARTICIPANT RECORD — CONFIDENTIAL INFORMATION —————————————
Please read carefully before signing.
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 (FACILITY) __________________________________________
located in the city of __________________________________
and state of _________________________________________.
Read and discuss this statement prior to signing it. You must
complete this Medical Statement, which includes the medical-history section, to enroll in the scuba training program. If you are a
minor, you must have this Statement signed by a parent.
Diving is an exciting and demanding activity. When performed
correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there
are dangers.
To scuba dive safely, you must 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 heart
trouble, a current cold or congestion, epilepsy, asthma, a severe
medical problem, or who is under the influence of alcohol or drugs
should not dive. If taking medication, consult your doctor and the
Instructor before participation in this program. You will also need to
learn from the Instructor the important safety rules regarding
breathing and equalization while 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 History section, review them with your
Instructor before signing.
Medical History
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.
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 a 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 presecription 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
attacks or strokes
• 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 problems
(panic attack, fear of closed or
open spaces)?
____ Epilepsy, seizures, convulsions or
take medications to prevent them?
____ Recurring 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 medication 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?
____ Hernia?
____ 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.
__________________________________________________________________________________________________
_______________________
SIGNATURE
DATE
__________________________________________________________________________________________________
_______________________
SIGNATURES OF PARENTS OR GUARDIANS WHERE APPLICABLE
DATE
© 1993 CONCEPT SYSTEMS, INC. Rev. 3/02, 3/03
ADRO:SSI:EDU:DIVER:STUDENT:MEDICAL:“Medical Exam 3/03”:ART FILE #1162-D
Reorder #1512RSTC
Middletown Scuba
17 Dolson Avenue • Middletown, NY 10940
845-343-2858 • [email protected]
Student
(Please print legibly)
Name __________________________________________ Birth Date ____________ Age ______
First
Initial
Last
Mailing Address _________________________________________________________________________
________________________________________________________________________________________
City _________________________________ State/Province _________________________________
Country __________________________________________ Zip/Postal Code _________________
)
(
)
Home Phone (_________________________
Business Phone ________________________________
Telex _______________________________ FAX ______________________________________
Name and address of your family or primary care physician:
Physician ____________________________ Clinic/Hospital _________________________________
)
Address _____________________________________ Phone ( _______________________________
Date of last physical examination __________________________________________________________
Name of examiner _____________________ Clinic/Hospital _________________________________
)
Address _____________________________________ Phone ( _______________________________
Were you ever required to have a physical for diving?
Yes
No If so, when? _____________
Physician
This person is an applicant 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. Please review Guidelines for Recreational Scuba Diver’s Physical Examination.
Physician’s Impression:
I find no medical conditions that I consider incompatible with diving.
I am unable to recommend this individual for diving.
Remarks _______________________________________________________________________________
I have reviewed Guidelines for Recreational Scuba Diver’s Physical Examination.
____________________________________________________________________________, M.D.
Physician’s Signature
Date ______________
Physician ____________________________ Clinic/Hospital _________________________________
)
Address ______________________________________________ Phone (______________________
Middletown Scuba
17 Dolson Avenue • Middletown, NY 10940
845-343-2858 • [email protected]
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845-343-2858 • [email protected]
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17 Dolson Avenue • Middletown, NY 10940
845-343-2858 • [email protected]
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