AIDA MÉDICAL STATEMENT

Freediving is a strenuous activity carried out in the underwater environment, which may, under certain conditions, increase your risk of injury. This risk may be significantly increased if you have certain physical conditions. These same physical conditions would not necessarily be a safety factor in other strenuous activities or sports. AIDA therefore uses the following questionnaire to make you aware of these conditions. Failure to address these conditions prior to engaging in breath-hold diving activity may endanger your health, your safety and the safety of any person you may dive with in the future.

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in freedive training. A positive response to a question does not necessarily disqualify you from freediving. A positive response means that there is a pre-existing condition that may affect your safety while freediving and you MUST seek the advice of a physician prior to engaging in freedive activities. The physician needs to sign at the bottom of the form to say that he/she finds no medical conditions incompatible with freediving if any “YES” box is ticked.

Please answer the following questions on your past or present medical history by ticking the box marked YES or NO. If you are not sure, answer YES.

Name of Freediver

1. Medication: Any medication taken on a regular basis either over-the-counter or prescribed by a physician?

YesNo

If yes, please specify

2. Mental and Mood Conditions: Current or history of mental illness or mood disorder including, but not limited to schizophrenia, paranoid disorder, bouts of hysteria.

YesNo

If yes, please specify

3. Neurological Conditions: Including, but not limited to any history of seizure disorder, stroke, brain surgery, repeated blackouts or fainting fits, severe migraine headaches, or aneurysm of the brain’s blood vessels.

YesNo

If yes, please specify

4. Cardiovascular Conditions: Including, but not limited to heart attack, heart surgery, irregular heartbeat, pacemaker, uncontrolled elevated blood pressure.

YesNo

If yes, please specify

5. Pulmonary Conditions: Including, but not limited to asthma, history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, severe damage to lung tissue, emphysema, any lung problem which interferes with your ability to breathe.

YesNo

If yes, please specify

6. Ear, nose and throat Conditions: Including, but not limited to tumor, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, persistent sinus infection, permanent holes of the eardrums, history of ruptured eardrum, permanent tubes in ear-drums, severely impaired hearing or hearing loss in one or both ears, major ear surgery.

YesNo

If yes, please specify

7. Eye Condition: Including, but not limited to severe myopia, retinal detachment, eye surgery.

YesNo

If yes, please specify

8. Diabetes Mellitus: Type I Diabetes (Insulin dependent) or Type II Diabetes, which requires Insulin or oral medication for control. Any form of Diabetes that is unstable, “brittle” or produces episodes of hypoglycemia (low blood sugar reactions), hyperglycemia (extremely high blood sugar with ketosis) or if there is related kidney disease, eye disease, heart disease or blood vessel disease.

YesNo

If yes, please specify

9. Freediving/Scuba Diving History: Including, but not limited to previous history of a diving accident, severe blackout, decompression sickness, decompression of the inner ear of air, reverse block, lung squeeze, any lung squeeze producing pink foam, pulmonary bleeding

YesNo

If yes, please specify

10. General Medical Problems: Any physical and/or emotional condition not mentioned that might affect your safety in an underwater environment or affect your judgment under times of physical or emotional stress.

YesNo

If yes, please specify

11. Pregnancy: If you are presently pregnant.

YesNo

I certify that I have answered the above questions accurately and honestly.

I am responsible for omission regarding my failure to disclose any current or past health condition.

Name of the freediver

Signature

Date of birth

Date

*If the Freediver is aged less than 18 years, this must also be signed by a parent/guardian Signature of participant ́ sparent or guardian:

AIDA MEDICAL STATEMENT

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