DSD PADI Medical Questionnaire

PADI Medical Questionnaire

Please Complete And Click Submit
Scuba Diving is an exciting and demanding activity. To Scuba Dive 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 before participating in this program.

The purpose of the Medical Questionnaire is to find out if you should be examined by a physician before participating in recreational diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving and you must seek the advice of a physician.
Full Name

First NameMiddle NameLast Name
Email
example@example.com
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Participant mail address

Participant Address

Participant Address

CityState / Province

Postal / Zip CodeCountry
Phone Number
Format: (000) 000-0000.
Gender

Discover Scuba Diving Knowledge and Safety Review

To continue your Discover Scuba Diving experience, you must complete this review under the direction of your PADI Professional BEFORE getting in the water.Check the appropriate box in response to each question:

Please answer the following questions on your past and 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 PADI Professional will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to a physician.

Rows	Yes/No
Do you currently have an ear infection?
Do you have a history of ear disease, hearing loss or problems with balance?
Do you have a history of ear or sinus surgery?
Are you currently suffering from a cold,congestion, sinusitis or bronchitis?
Do you have a history of respiratory problems,severe attacks of hay fever or allergies, or lung disease?
Have you had a collapsed lung (pneumothorax) or history of chest surgery?
Do you have active asthma or history of emphysema or tuberculosis?
Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?
Do you have behavioural health, mental or psychological problems or a nervous system disorder?
Are you or could you be pregnant?
Do you have a history of colostomy?
Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?
Do you have a history of high blood pressure, angina, or take medication to control blood pressure?
Are you over 45 and have a family history of heart attack or stroke?
Do you have a history of bleeding or other blood disorders?
Do you have a history of diabetes?
Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?
Do you have a history of back, arm or leg problems following an injury, fracture or surgery?
Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?

Non-Agency Disclosure and Acknowledgment Agreement
Liability Release and Assumption of Risk Agreement
(Liability Release and Assumption of Risk Agreement continued)

In consideration of being allowed to participate in this program, I hereby personally assume all risks for any harm, injury or damage, whether foreseen or unforeseen, that may befall me while participating in this program, including but not limited to the knowledge development, confined water and/or open water activities.

I further release and hold harmless the Discover Scuba Diving program and the Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my participation in this program.

I further understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program and that if I am injured as a result of heart attack, panic, hyperventilation, etc., that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same.

I further state that I am of lawful age and legally competent to sign this Liability Release and Assumption of Risk Agreement, or that I have acquired the written consent of my parent or guardian.

I understand that the terms herein are contractual and not a mere recital and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this, Agreement is found to be unenforceable or invalid, that provision shall he severed from this Agreement.The remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein.

I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns or beneficiaries may have to sue the Released Parties resulting from my death. I further represent that I have the authority to do so and that my heirs, assigns and beneficiaries will be stopped from claiming otherwise because of my representations to the Released Parties.
Name

First NameLast Name
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year(Day/Month/Year)
Guardian's Name (if applicable)

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year(Day/Month/Year)
Should be Empty:

PADI Medical Questionnaire

Discover Scuba Diving Knowledge and Safety Review

Non-Agency Disclosure and Acknowledgment Agreement

Liability Release and Assumption of Risk Agreement