MEDICAL STATEMENT

Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in freediving and scuba diving and of the conduct required of you during the freediving and/or scuba training program. Your signature on this statement is required for you to participate in the freediving and/ or scuba training program offered by:

the important safety rules regarding breathing must not be extremely overweight or out of Read and discuss this statement prior to condition. Diving can be strenuous under signing it. You must complete this Medical and equalization while freediving and/or scuba certain conditions. Your respiratory and Statement, which includes the medical-history diving. Improper use of freediving and/or scuba circulatory systems must be in good health. All section, to enroll in the freediving and/or scuba equipment can result in serious injury. You body air spaces must be normal and healthy. training program. If you are a minor, you must must be thoroughly instructed in its use under A person with heart trouble, a current cold or have this Statement signed by a parent. direct supervision of a qualified Instructor to congestion, epilepsy, asthma, a severe medical Diving is an exciting and demanding activity. use it safely. problem, or who is under the influence of When performed correctly, applying correct If you have any additional questions alcohol or drugs should not dive. If taking techniques, it is very safe. When established regarding this Medical Statement or the medication, consult your doctor and the safety procedures are not followed, however, Medical History section, review them with your Instructor before participation in this program. there are dangers. You will also need to learn from the Instructor To freedive and/or scuba dive safely, you Instructor before signing.

The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational freediving and/or scuba 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 request that you consult with a physician prior to participating in freediving and/or scuba diving. Your Instructor will supply you with a medical statement and guidelines for Recreational Freediving & Scuba Diving physical examination to take to your physician.

(with the exception of birth control or anti-malarial)

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.

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Date of last physical examination

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.

I HAVE REVIEWED GUIDELINES FOR RECREATIONAL SCUBA DIVER’S PHYSICAL EXAMINATION.

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Recreational scuba (self contained underwater breathing apparatus) can provide recreational divers with an enjoyable sport safer than many other activities. The risk of diving is increased by certain physical conditions, which the relationship to diving may not be readily obvious. Thus, it is important to screen divers for such conditions. The Recreational Scuba Diver’s Physical Examination focuses on conditions that may put a diver at increased risk for decompression sickness, pulmonary overinflation syndrome with subsequent arterial gas embolization and other conditions such as loss of consciousness, which could lead to drowning. Additionally, the diver must be able to withstand some degree of cold stress, the physiological effects of immersion and the optical effects of water and have sufficient physical and mental reserves to deal with possible emergencies. The history, review of systems and physical examination should include, as a minimum, the points listed below. The list of conditions that might adversely affect the diver is not all-inclusive, but contains the most commonly encountered medical problems. The brief introductions should serve as an alert to the nature of the risk posed by each medical problem. The potential diver and his or her physician must weigh the pleasures to be had by diving against an increased risk of death or injury due to the individual’s medical condition. As with any recreational activity, there are no data for diving enabling the calculation of an accurate mathematical probability of injury. Experience and physiological principles only permit a qualitative assessment of relative risk. For the purposes of this document, Severe Risk implies that an individual is believed to be at substantially elevated risk of decompression sickness, pulmonary or otic barotrauma or altered consciousness with subsequent drowning, compared with the general population. The consultants involved in drafting this document would generally discourage a student with such medical problems from diving. Relative Risk refers to a moderate increase in risk, which in some instances may be acceptable. To make a decision as to whether diving is contraindicated for this category of medical problems, physicians must base their judgement on an assessment of the individual patient. Some medical problems which may preclude diving are temporary in nature or responsive to treatment, allowing the student to dive safely after they have resolved. Diagnostic studies and specialty consultations should be obtained as indicated to determine the diver’s status. A list of references is included to aid in clarifying issues that arise. Physicians and other medical professionals of the Divers Alert Network (DAN) associated with Duke University Health System are available for consultation by phone (919) 684-2948 during normal business hours. For emergency calls, 24 hours, 7 days a week, call (919) 684-8111 or (919) 684-4DAN (collect Related organizations exist in other parts of the world – DAN Europe in Italy +39 039 605 7858, DAN S.E.A.P. in Australia +61 3 9886 9166 and Divers Emergency Service (DES) in Australia +61-8-8212-9242, DAN Japan +81-33590-6501 and DAN Southern Africa +27-11-242-0380. There are also a number of informative websites offering similar advice.

• Neurological abnormalities affecting a diver’s ability to perform exercise should be assessed according to the degree of compromise. Some diving physicians feel that conditions in which there can be a waxing and waning of neurological symptoms and signs, such as migraine or demyelinating disease, contraindicate diving because an exacerbation or attack of the preexisting disease (e.g.: a migraine with aura) may be difficult to distinguish from neurological decompression sickness. A history of head injury resulting in unconsciousness should be evaluated for risk of seizure. Severe Risk Conditions: Any abnormalities where there is a significant probability of unconsciousness, hence putting the diver at increased
• Complicated Migraine Headaches whose symptoms or severity risk of drowning. Divers with spinal cord or brain abnormalities where impair motor or cognitive function, neurologic manifestations perfusion is impaired may be at increased risk of decompression
• History of Head Injury with sequelae other than seizure sickness.
• Herniated Nucleus Pulposus
• Peripheral Neuropathy
• Multiple Sclerosis
• History of seizures other than childhood febrile seizures
• Trigeminal Neuralgia
• History of Transient Ischemic Attack (TIA) or Cerebrovascular
• History of spinal cord or brain injury Accident (CVA)
• History of Serious (Central Nervous System, Cerebral or Inner Ear) Decompression Sickness with residual deficits
• History of cerebral gas embolism without residual where pulmonary air trapping has been excluded and for which there is a satisfactory explanation and some reason to believe that the probability of recurrence is low.

Some conditions are as follows:

Relative Risk Conditions: The diagnoses listed below potentially render the diver unable to meet the exertional performance requirements likely to be encountered in recreational diving. These conditions may lead the diver to experience cardiac ischemia and its consequences. Formalized stress testing is encouraged if there is any doubt regarding physical performance capability. The suggested minimum criteria for stress testing in such cases is 13 METS.* Failure to meet the exercise criteria would be of significant concern. Conditioning and retesting may make later qualification possible. Immersion in water causes a redistribution of blood from the periphery into the central compartment, an effect that is greatest in cold water. The marked increase in cardiac preload during immersion can precipitate pulmonary edema in patients with impaired left ventricular function or significant valvular disease. The effects of immersion can mostly be gauged by an assessment of the diver’s performance while swimming on the surface. A large proportion of scuba diving deaths in North America are due to coronary artery disease. Before being approved to scuba dive, individuals older than 40 years are recommended to undergo risk assessment for coronary artery disease. Formal exercise testing may be needed to assess the risk.

* METS is a term used to describe the metabolic cost. The MET at rest times the resting level, and so on. The resting energy cost (net oxygen requirement) is thus standardized. (Exercise Physiology; Clark, Prentice Hall, 1975 © SSI International GmbH, 2017 | 470356-EN

• History of Coronary Artery Bypass Grafting (CABG)
• Percutaneous Balloon Angioplasty (PCTA) or Coronary Artery Disease (CAD)
• History of Myocardial Infarction
• Congestive Heart Failure
• Hypertension
• History of dysrythmias requiring medication for suppression
• Valvular Regurgitation
• Pacemakers — The pathologic process that necessitated should be addressed regarding the diver’s fitness to dive. In those instances where the problem necessitating pacing does not preclude diving, will the diver be able to meet the performance criteria?

Severe Risks: Venous emboli, commonly produced during decompression, may cross major intracardiac right-to-left shunts and enter the cerebral or spinal cord circulations causing neurological decompression illness. Hypertrophic cardiomyopathy and valvular stenosis may lead to the sudden onset of unconsciousness during exercise.

* NOTE: Pacemakers must be certified by the manufacturer as able to withstand the pressure changes involved in recreational diving.

Any process or lesion that impedes airflow from the lung places the diver at risk for pulmonary overinflation with alveolar rupture and the possibility of cerebral air embolization. Asthma (reactive airway disease), Chronic Obstructive Pulmonary Disease (COPD), cystic or cavitating lung diseases may all cause air trapping. The 1996 Undersea and Hyperbaric Medical Society (UHMS) consensus on diving and asthma indicates that for the risk of pulmonary barotrauma and decompression illness to be acceptably low, the asthmatic diver should be asymptomatic and have normal spirometry before and after an exercise test. Inhalation challenge tests (e.g.: using histamine, hypertonic saline or methacholine) are not sufficiently standardized to be interpreted in the context of scuba diving. A pneumothorax that occurs or reoccurs while diving may be catastrophic. As the diver ascends, air trapped in the cavity expands and could produce a tension pneumothorax. In addition to the risk of pulmonary barotrauma, respiratory disease due to either structural disorders of the lung or chest wall or neuromuscular disease may impair exercise performance. Structural disorders of the chest or abdominal wall (e.g.: prune belly), or neuromuscular disorders, may impair cough, which could be life threatening if water is aspirated. Respiratory limitation due to disease is compounded by the combined effects of immersion (causing a restrictive deficit) and the increase in gas density which increases in proportion to the ambient pressure (causing increased airway resistance Formal exercise testing may be helpful.

• History of Asthma or Reactive Airway Disease (RAD)*
• History of Exercise Induced Bronchospasm (EIB)*
• History of solid, cystic or cavitating lesion*
• Pneumothorax secondary to: Thoracic Surgery Trauma or Pleural Penetration* Previous Overinflation Injury*
• Obesity
• History of Immersion Pulmonary Edema Restrictive Disease*
• Interstitial lung disease: May increase the risk of pneumothorax
• * Spirometry should be normal before and after exercise

• History of spontaneous pneumothorax: Individuals who have experienced spontaneous pneumothorax should avoid diving, even after a surgical procedure designed to prevent recurrence (such as pleurodesis Surgical procedures either do not correct the underlying lung abnormality (e.g.: pleurodesis, apical pleurectomy) or may not totally correct it (e.g.: resection of blebs or bullae
• Impaired exercise performance due to respiratory disease.
• Active Reactive Airway Disease, Active Asthma, Exercise Induced Bronchospasm, Chronic Obstructive Pulmonary Disease or history of same with abnormal PFTs or a positive exercise challenge are concerns for diving.

As with other organ systems and disease states, a process which chronically debilitates the diver may impair exercise performance. Additionally, dive activities may take place in areas remote from medical care. The possibility of acute recurrences of disability or lethal symptoms must be considered.

• Peptic Ulcer Disease associated with pyloric obstruction or severe reflux
• Unrepaired hernias of the abdominal wall large enough to contain bowel within the hernia sac could incarcerate.

• Inflammatory Bowel Disease
• Functional Bowel Disorders

• Altered anatomical relationships secondary to surgery or malformations that lead to gas trapping may cause serious problems.
• Gas trapped in a hollow viscous expands as the divers surfaces and can lead to rupture or, in the case of the upper GI tract, emesis.
• Emesis underwater may lead to drowning.

• Gastric outlet obstruction of a degree sufficient to produce recurrent vomiting
• Chronic or recurrent small bowel obstruction
• Severe gastroesophageal reflux
• Achalasia
• Paraesophageal Hernia

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Relative impairment of mobility, particularly in a boat or ashore with equipment weighing up to 18 kgs/40 pounds must be assessed. Orthopaedic conditions of a degree sufficient to impair exercise performance may increase the risk.

• Amputation
• Scoliosis must also assess impact on respiratory function and exercise performance.
• Aseptic Necrosis possible risk of progression due to effects of decompression (evaluate the underlying medical cause of decompression may accelerate/escalate the progression

Abnormalities resulting in altered rheological properties may theoretically increase the risk of decompression sickness. Bleeding disorders could worsen the effects of otic or sinus barotrauma, and exacerbate the injury associated with inner ear or spinal cord decompression sickness. Spontaneous bleeding into the joints (e.g.: in hemophilia) may be difficult to distinguish from decompression illness.

• Sickle cell trait
• Polycythemia Vera
• Leukemia
• Hemophilia/Impaired Coagulation

With the exception of diabetes mellitus, states of altered hormonal or metabolic function should be assessed according to their impact on the individual’s ability to tolerate the moderate exercise requirement and environmental stress of sport diving. Obesity may predispose the individual to decompression sickness, can impair exercise tolerance and is a risk factor for coronary artery disease.

• Hormonal excess or deficiency
• Obesity
• Renal insufficiency

• The potentially rapid change in level of consciousness associated with hypoglycemia in diabetics on insulin therapy or certain oral hypoglycemia medications can result in drowning.
• Diving is therefore generally contraindicated, unless associated with a specialized program that addresses these issues. Pregnancy: The effect of venous emboli formed during decompression on the fetus has not been thoroughly investigated.
• Diving is therefore not recommended during any stage of pregnancy or for women actively seeking to become pregnant.

Behavioral: The diver’s mental capacity and emotional make-up are important to safe diving. The student diver must have sufficient learning abilities to grasp information presented to him by his instructors, be able to safely plan and execute his own dives and react to changes around him in the underwater environment. The student’s motivation to learn and his ability to deal with potentially dangerous situations is also crucial to safe scuba diving.

• Developmental delay
• History of drug or alcohol abuse
• History of previous psychotic episodes
• Use of psychotropic medications

• Inappropriate motivation to dive — solely to please spouse, partner or family member, to prove oneself in the face of personal fears
• Inappropriate motivation to dive — solely to please spouse, partner or family member, to prove oneself in the face of personal fears
• Claustrophobia and agoraphobia
• Active psychosis
• History of untreated panic disorder
• Drug or alcohol abuse

Equalization of pressure must take place during ascent and descent between ambient water pressure and the external auditory canal, middle ear and paranasal sinuses. Failure of this to occur results at least in pain and in the worst case rupture of the occluded space with disabling and possible lethal consequences. The inner ear is fluid filled and therefore noncompressible. The flexible interfaces between the middle and inner ear, the round and oval windows are, however, subject to pressure changes. Previously ruptured but healed round or oval window membranes are at increased risk of rupture due to failure to equalize pressure or due to marked overpressurization during vigorous or explosive Valsalva maneuvers.

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The larynx and pharynx must be free of an obstruction to airflow. The laryngeal and epiglotic structure must function normally to prevent aspiration. Mandibular and maxillary function must be capable of allowing the patient to hold a scuba mouthpiece. Individuals who have had mid-face fractures may be prone to barotrauma and rupture of the air filled cavities involved.

• Recurrent otitis externa
• Significant obstruction of external auditory canal
• History of significant cold injury to pinna
• Eustachian tube dysfunction
• Recurrent otitis media or sinusitis
• History of TM perforation
• History of tympanoplasty
• History of mastoidectomy
• Significant conductive or sensorineural hearing impairment
• Facial nerve paralysis not associated with barotrauma
• Full prosthedontic devices
• History of mid-face fracture
• Unhealed oral surgery sites
• History of head and/or neck therapeutic radiation
• History of temperomandibular joint dysfunction
• History of round window rupture

• Monomeric TM
• Open TM perforation
• Tube myringotomy
• History of stapedectomy
• History of ossicular chain surgery
• History of inner ear surgery
• Facial nerve paralysis secondary to barotrauma
• Inner ear disease other than presbycusis
• Uncorrected upper airway obstruction
• Laryngectomy or status post partial laryngectomy
• Tracheostomy
• Uncorrected laryngocele
• History of vestibular decompression sickness

1. Bennett, P. & Elliott, D (eds Saunders Company Ltd., London, England. 2. Bove, A., & Davis, J. 91990 Diving Medicine. 2nd Ed., W.B. Saunders Company, 10. Undersea and Hyperbaric Medical Society (UHMS) www.UHMS.org Philadelphia, PA 3. Davis, J., & Bove, A. (1986 “Medical Examination of Sport Scuba Divers, Medical Seminars, DiversAlertNetwork.org Inc.,” San Antonio, TX 4. Dembert, M. & Keith, J. (1986 “Evaluating the Potential Pediatric Scuba Diver.” AJDC, Vol. 140, November. 7858 5. Edmonds, C., Lowry, C., & Pennefether, J. (1992 3rd Ed., Diving and Subaquatic Medicine. 13. Divers Alert Network S.E.A.P., P.O. Box 384, Ashburton, Australia, telephone 61-3-9886- Butterworth & Heineman Ltd., Oxford, England. 9166 6. Elliot, D. (Ed1994 “Medical Assessment of Fitness to Dive.” Proceedings of an 14. Divers Emergency Service, Australia, www.rah.sa.gov.au/hyperbaric, telephone 61-8- International Conference a the Edinburgh Conference Centre, Biomedical Seminars, 8212-9242 Surry, England. 15. South Pacific Underwater Medicine Society (SPUMS), P.O. Box 190, Red Hill South, 7. “Fitness to Dive,” Proceedings of the 34th Underwater & Hyperbaric Medical Society Victoria, Australia, www.spums.org.au Workshop (1987) UHMS Publication Number 70 (WS-FD) Bethesda, MD. 16. European Underwater and Baromedical Society, www.eubs.org 8. Neuman, T. & Bove, A. (1994 “Asthma and Diving.” Ann. Allergy, Vol. 73, October, O’Conner & Kelsen.

1993 The Physiology and Medicine of Diving. 4th Ed., W.B. 9. Shilling, C. & Carlston, D. & Mathias, R. (eds) (1984 The Physician’s Guide to Diving Medicine. Plennum Press, New York, NY.

11. Divers Alert Network (DAN) United States, 6 West Colony Place, Durham, NC www.

12. Divers Alert Network Europe, P.O. Box 64026 Roseto, Italy, telephone non-emergency line: weekdays office hours+39-085-893-0333, emergency line 24 hours: +39-039-605-

Paul A. Thombs, M.D. Hyperbaric Medical Center St. Luke’s Presbyterian Hospital Denver, CO

Robert W. Goldmann, M.D. St. Luke’s Hospital Milwaukee, WI

Richard Vann, Ph.D Duke University Medical Center Durham, NC

Richard E. Moon, M.D., F.A.C.P.,

Peter Bennett, Ph.D., D.Sc. Duke University Medical Center Durham, NC pbennett@dan.duke.edu

Departments of Anesthesiology and Pulmonary Medicine Duke University Medical Durham, NC

Paul G. Linaweaver, M.D., F.A.C.P. Santa Barbara Medical Clinic Undersea Medical Specialist

Yoshihiro Mano, M.D. Professor Tokyo Medical and Dental University Tokyo, Japan y.mano.ns@tmd.ac.jp

Charles E. Lehner, Ph.D Department of Surgical Sciences University of Wisconsin Madison, WI celhner@facstaff.wisc.edu

William Clem, M.D. Hyperbaric Consultant Division Presbyterian/St. Luke’s Medical Center Denver, CO

Alessandro Marroni, M.D. Director, DAN Europe Roseto, Italy

James Vorosmarti, M.D. 6 Orchard Way South Rockville, MD

Edmond Kay, M.D., F.A.A.F.P Dive Physician & Asst. Clinical Prof. of Family Medicine University of Washington Seattle, WA ekay@u.washington.edu

Undersea & Hyperbaric Medical Society 10531 Metropolitan Avenue Kensington, MD 20895

Diver’s Alert network (DAN) 6 West Colony Place Durham, NC 27705

John M. Alexander, M.D. Northridge Hospital Los Angeles, CA

Hugh Greer, M.D. Santa Barbara, CA hdgblgfpl@aol.com

Christopher J. Acott, M.B.B.S, Dip.

Des Gorman, B.S., M.B.Ch.B, F.A.C.O.M., F.A.F.O.M, Ph.D Professor of Medicine University of Auckland Auckland, NZ d.gorman@auckland.ac.nz

Physician in Charge, Diving Medicine Royal Adelaide Hospital Adelaide, SA 5000, Australia

Keith Van Meter, M.D., F.A.C.E.P. Assistant Clinical Professor of Surgery Tulane University School of Medicine New Orleans, LA

Simon Mitchell, MB.ChB., DipDHM, Ph.D. Wesley Centre for Hyperbaric Medicine Medical Director Sandford Jackson Bldg., 30 Chasely Street Auchenflower, QLD 4066 Australia smithchell@wesley.com.au

Christopher W. Dueker, TWS, M.D. Atherton, CA chrisduek@aol.com

Chris Edge, M.A., Ph.D, M.B.B.S,

Jan Risberg, M.D., Ph.D NUI, Norway Alf O. Frubakk, M.D., Ph.D Norwegian University of Science and Technology Trondheim, Norway alfb@medisin.ntnu.no

Tom S. Neuman, M.D., F.A.C.P.,

Nuffield Department of Anaesthetics Radcliffe Infirmary Oxford, United Kingdom cjedge@diver.demon.co.uk

Associate Director, Emergency Medical Services Professor of Medicine and Surgery University of California at San Diego San Diego, CA

Karen B. Van Hoesen, M.D. Associate Clinical Professor UCSD Diving Medicine Center University of California at San Diego San Diego, CA

This form has been developed in conjunction with the Recreational Scuba Training Council

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