HEALTH DECLARATION FORM

Read this statement prior to signing it. You must complete this additional Medical Statement to enroll in a diver training program or to participate in any diving activity. If you are a minor, you must have this Statement signed by your parent or guardian.

The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Should you have any existing conditions that could compromise your fitness to dive, you will need to consult with a diving medical specialist. A positive response means that there may be a preexisting condition that may affect your safety while diving. Please answer the following questions with a YES or NO. If you are not sure, answer YES. If any of these statements apply to you, we must request that you consult with a physician, preferably a Diving Medicine Specialist prior to participating in diving activities.

Within the 40 days immediately preceding the date of this Health Declaration Form, have you:

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR– SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

YESNo

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?

YESNO

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNIZED HEALTH OR REGULATORY AUTHORITY?*

YesNo

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

YesNo

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions.

Name*

First NameLast Name

Date*

Date

Signature*

Guardian's Full Name

First NameLast Name

Date

Signature

ADDITIONAL DECLARATIONS – COVID-19*

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by 72 AQUATICS, and will take all reasonable preventive steps that may be recommended by 72 AQUATICS, and/or any relevant public authority.I WILL accept and observe all instructions by 72 AQUATICS intended to abide by all existing regulations, required to help prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities.I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to 72 AQUATICS to retain this Declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.

Full Name*

Date*

Date

Signature*

Guardian’s Full Name

Date

Signature

COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalesce before returning to full activities – a process that can take weeks or months depending on symptom severity (1).

MEDICAL RECOMMEDATIONS (2):

Divers who have had symptomatic COVID-19, should wait a minimum of TWO months, preferable THREE, before resuming their diving activities.
Divers who have tested positive with COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.
Divers who have been hospitalized with pulmonary symptoms related to COVID-19, should, after a three-month waiting period, undergo complete pulmonary function testing as well as a cardiac evaluation with echocardiography and exercise test (exercise electrocardiography) to ascertain normal cardiac function prior to your return to diving.

Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe / Divers Alert Network

(1) Return to Diving Post COVID-19 - issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.

(2) Diving after COVID-19 pulmonary infection. A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG.)

The present is a sample of Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

The Form has been developed by the DAN Europe Medical Division team, based on information available as of May 2020. The epidemiological situation is constantly evolving.As a result, this document may be subject to changes and updates.

HEALTH DECLARATION FORM - COVID-19

DIVER MEDICAL QUESTIONNAIRE

PLEASE NOTE

GENERAL RECOMMENDATION

REFERENCES