• DIVER REGISTRATION & MEDICAL QUESTIONNAIRE

    • Personal Information (adult or legal guardian)  
    • Date of Birth*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Gender*
    •  -
    •  -
    • Which aquatic activity will you do?*
    • Diving Details (if you are not a diver yet, write no or 0) 
    • Buscar archivos
      Drag and drop files here
      Choose a file
      Cancelof
    • Attach a photo or a document of other diving course you have done
    • Do you have diving insurance?*
    • Buscar archivos
      Drag and drop files here
      Choose a file
      Cancelof
    • Last Dive Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Arrival Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Departure Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Diving Gear (If you don't know, write down only weight and height) 
    • PARTICIPANT MEDICAL QUESTIONNAIRE 

    • 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 fitness 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.

      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.

    • 1. I have had problems with my lungs/breathing, heart, blood.*
    • 2. I am over 45 years of age.*
    • 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 fitnessor health reasons within the past 12 months.*
    • 4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
    • 5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
    • 6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. *
    • 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.*
    • 8. I have had back problems, hernia, ulcers, or diabetes.*
    • 9. I have had stomach or intestine problems, including recent diarrhea.*
    • 10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

    • Participant Statement & Signature

      If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

      * If you answered YES to any of the questions (except number 2 without any of the options in the added options), please read and agree to the statement above by signing and dating it AND take this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

    • UNDERAGE Personal information of the child and medical questionnaire (if applicable) 
    • Date of Birth
       - -
      2 digit day, 2 digit month, 4 digit year
    • Gender
    • 1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.
    • 2. I am over 45 years of age.
    • 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 fitnessor health reasons within the past 12 months.
    • 4. I have had problems with my eyes, ears, or nasal passages/sinuses.
    • 5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
    • 6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
    • 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.
    • 8. I have had back problems, hernia, ulcers, or diabetes.
    • 9. I have had stomach or intestine problems, including recent diarrhea.
    • 10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).

    • * By giving this information, as the legal guardian of this minor, I give my consent to carry out the aquatic activity.

    • DECLARATION AND SIGNATURE OF THE PARTICIPANT 
    • Should be Empty: