DIVER REGISTRATION & MEDICAL QUESTIONNAIRE

DIVER REGISTRATION & MEDICAL QUESTIONNAIRE
- Full name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Date of Birth
  
  DayMonthYear
  Date
- Gender
- ID/Passport number
- Phone Number
  
  Area CodePhone Number
- Emergency Contact
  
  Area CodePhone Number
- E-mail
  example@example.com
- Are you staying in the Hotel?
- Hotel - Room Number
- Which aquatic activity will you do?
- How did you hear about us?
- Other (specify)
- Dive Level (certification)
- Diver's number of dives (approximate)
- Attach a photo or a document of the highest ranking diving course
  
  Cancelof
- Attach a photo or a document of other diving course you have done
- Do you have diving insurance?
- Attach a photo or a document of the diving insurance (where the policy number and validity date are shown)
  
  Cancelof
- Last Dive Date
  
  DayMonthYear
  Date
- Arrival Date
  
  DayMonthYear
  Date
- Departure Date
  
  DayMonthYear
  Date
- Shoe (size)
- Wet suit (size)
- Regulator
- Mask
- Buoyancy Compensator Device (size)
- Fins (size)
- Height (cm)/Weight (kg)
- 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).
- Other health problems
- 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.
- Full Name
  
  NombreApellido
- ID/Passport number
- Date of Birth
  
  DayMonthYear
  Date
- 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).
- Other health problems
- * By giving this information, as the legal guardian of this minor, I give my consent to carry out the aquatic activity.
- Signature
- Should be Empty: