Final Revised Medical Only 2021

Medical
- MEDICAL STATEMENT 10346 - COVID
Minors (a person under 18) will require parental guidence and assistance completing this form. You can also request to complete a physical version of this form.
Medical Question Short Text Entry
First Name*
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Date of Birth (xx/xx/xxxx)*

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Program you have signed up for:
Address
Certification Agency and #
Only if you are already certified
Certification #
Signature not required
By checking this box I confirm that the above information which I have provided is true and correct.
Signature of participant

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Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving ftness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women: If you are pregnant, or attempting to become pregnant, do not dive.
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No Emergency Contact to Zoho
No Emergency provided to pdf
Medical Waiver:
Medical question at top of page 1:

YESNO
Medical YES
Medical NO
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NoYes
Question 1: I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*

NoYes

Question 1. Box A Closes
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 2: I am over 45 years of age.*

NoYes

Question 2 Box B END
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 3: I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200meters/yards without resting), OR I have been unable to participate in a normal physical activity due to ftnessor health reasons within the past 12 months.*

NoYes

Question 3. Box WARNING TEXT END
Question 4: I have had problems with my eyes, ears, or nasal passages/sinuses.*

NoYes

Question 4 Box C END
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 5: I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*

NoYes

Question 5 Box WARNING TEXT END
Question 6: I have lost consciousness, had migraine headaches, seizures, stroke, signifcant head injury, or suffer frompersistent neurologic injury or disease.*

NoYes

Question 6 Box D END
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 7: I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*

NoYes

Question 7 Box E END
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 8: I have had back problems, hernia, ulcers, or diabetes.*

NoYes

Question 8 Box F END
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 9: I have had stomach or intestine problems, including recent diarrhea.*

NoYes

Question 9 Box G END
You will need approval from your physician prior to attending this program. Please continue completing this form. A waiver will be emailed to you with instructions for you and your physician. This must be done before any in-water training can occur.
Question 10: I am taking prescription medications (with the exception of birth control or anti-malarial drugs other thanmefoquine/Lariam).*

NoYes

Question 10 Box WARNING TEXT END

Participant Signature Box NO TEXT END

Participant Signature Box YES TEXT END
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Signature of participant*

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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.
Parent/guardian signature of participant is required:
Date

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Signature of parent or guardian*

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Instructor Name Printed
Facility Name Printed

**Please read carefully before signing:**

I understand and agree that PADI Members “Members”, including Scuba Fusion Dive Center #21058 and/or any individual PADI Instructors and Divemasters associated with the program in which I am participat ing, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI Americas, Inc, or its parent, subsidiary and affiliated corporations “PADI” I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver train ing programs, it is not responsible for, nor does it have the right to control, the operation of the Members’ business activities and the day-to day conduct of PADI programs and supervision of divers by the Members or their associated staff. I further understand and agree on behalf of myself, my heirs and my estate that in the event of an injury or death during this activity, neither I nor my estate shall seek to hold PADI liable for the actions, inactions or negligence of Scuba Fusion Dive Center #21058 and/or the instructors and divemasters associated with the activity.

**Liability Release and Assumption of Risk Agreement**
I, __{nameCombined}__ , hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I understand that diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. I further understand that the open water diving trips which are necessary for training and for certification may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site. I understand and agree that neither my instruc tor(s), all staff associated with Scuba Fusion Dive Center, the facility through which I receive my instruction, Scuba Fusion Dive Center #21058, nor PADI Americas, Inc., nor its affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur as a result of my participation in this diving program or as a result of the negligence of any party, including the Released Parties, whether passive or active. In consideration of being allowed to participate in this course (and optional Adventure Dive), hereinafter referred to as “program,” I hereby personally assume all risks of this program, whether foreseen or unforeseen, that may befall me while I am a participant in this program including, but not limited to, the academics, confined water and/or open water activities. I further release, exempt and hold harmless said program and Re-leased Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in this program including both claims arising during the program or after I receive my certification.	I also 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, drowning or any other cause, that I expressly as-sume 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, or that I have acquired the written consent of my parent or guardian. I understand 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 Agree-ment is found to be unenforceable or invalid, that provision shall be 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 benefi-ciaries may have to sue the Released Parties resulting from my death. I further represent I have the authority to do so and that my heirs, assigns, or beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties. I _{nameCombined}_ BY THIS INSTRUMENT AGREE TO EXEMPT AND RELEASE MY INSTRUCTORS, _all staff associated with Scuba Fusion Dive Center_, THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION, _Scuba Fusion Dive Center #21058_, AND PADI AMERICAS, INC., AND ALL RELATED ENTITIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, INCLUDING, BUT NOT LIMITED TO, THE NEGLI-GENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE.

I CONFIRM THAT I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGEMENT AGREEMENT AND LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS.
Full Name
Full Name Again
Signature of participant*

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Date (Day / Month / Year)*

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Signature of parent or legal guardian*

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understand that as a diver I should:
Participants signature*

Clear
Date (Day/Month/Year)*

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Signature of parent or guardian*

Clear
Date (Day/Month/Year)*

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liability Signed
Medical Signed
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Medical See Waiver
Would you like a copy of this medical emailed to you?*

YesNo

Email question end
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