• Diver medical participant questionnaire

  • This document "Diver medical participant questionnaire"
    must be accompanied by the document "Certified Divers Information Sheet".

    • Mandatory to read 

    • 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.

    • Information to be completed 

    • 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.

    • 1- I have had lung/respiratory, heart, blood problems*
    • Rows
    • 2- I am over 45 years old*
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    • 3- I have difficulty making moderate physical efforts (for example, walking 2 km in 15 minutes or swimming 200 meters without resting), or: I have not been able to participate in normal physical activity due to fitness or health reasons for 12 months.*
    • 4- I had problems with my eyes, ears, nasal passages or sinuses.*
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    • 5- I have had surgery in the past 12 months; or: I have chronic problems related to a previous surgery.*
    • 6- I have fainted, had migraines, seizures, stroke, major head injury or persistent neurological damage or disease.*
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    • 7- I am currently undergoing treatment (or have required treatment in the past five years) for psychological problems, personality disorders, panic attacks, or drug or alcohol dependency; or, I have been diagnosed with a learning disability.*
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    • 8- I have had back problems, hernia, ulcers and diabetes.*
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    • 9- I have had stomach or bowel problems, including recent diarrhea.*
    • Rows
    • 10- I am taking prescription medication (except for contraceptives or antimalarials other than mefloquine (Lariam).*

    • Participant's 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.


      Participant Declaration: I have answered all questions truthfully and understand that I accept responsibility for the consequences resulting from any question I answered inaccurately, or from my failure to disclose any existing or past health problems.

    • Birthdate*
       - -

    • If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2,

      • Please read, sign and date the above statement
      • A medical certificate less than one year old is required.
        Participation in the dives requires the approval of your physician.
    • Date*
       - -
    • Should be Empty: