Diving Medical Consultation

1

Name* This field is required.As it should appear on your certificate

First Name

Last Name

2

Date of Birth* This field is required.

Date

3

Age at the time of your intended dive(s)* This field is required.Please note, we can only provide online diving medicals for divers between the ages of 14-49.

We recommend divers under 14 or over 50 undertake in-personal dive medical assessments.

4

Sex* This field is required.

Female

Male

Prefer not to say

5

Email * This field is required.(where the certificate will be delivered)

6

Phone* This field is required.This number will be used to inform you when your certificate is ready, and may be used by the clinical team to contact you if any further information is required.

7

Address

Street Address

Street Address Line 2

City

County

Post Code

Country

8

Please describe any health related issues you have consulted your GP about in the the last 3 years:

9

Have you been admitted to hospital for any reason in the past 3 years?* This field is required.

YESNO

10

Please describe your hospital admission(s)

11

Do you take any medication (excluding contraception and vitamins)?* This field is required.

YESNO

12

Please list all regular medication you take:

13

Are you pregnant or have you given birth in the last 3 months?* This field is required.

YESNO

14

Please provide details regarding your pregnancy

15

BMI (please enter height and weight)* This field is required.Click the conversion icon below to switch between Imperial and Metric units

16

Blood Pressure* This field is required.

17

Heart Rate at restIf you do not have a heart rate monitor, sit quietly for ten minutes, then place 2 fingers on your pulse and count the beats for 15 seconds. Multiply that number by 4.

18

Have you ever suffered from a pneumothorax or pulmonary hypertension?* This field is required.

YESNO

19

Please provide details:* This field is required.

20

Do you suffer from any COPD or Asthma?* This field is required.

YESNO

21

Please provide further details of your COPD or Asthma:* This field is required.

22

Have you had an exacerbation within the last 5 years?* This field is required.

YESNO

23

When was your last exacerbation and how many exacerbations do you tend to suffer from per year?* This field is required.

24

How often do you use your reliever inhaler, and when did you last use it?* This field is required.Reliever inhaler is sometimes called the "blue" inhaler

25

Do you suffer from a wheeze when you exercise, experience strong emotion, or are exposed to cold air?* This field is required.

YESNO

26

Do you suffer from sleep apnoea or any other breathing/airway difficulty?* This field is required.

YESNO

27

Please provide details:

28

Have you been diagnosed with High Blood Pressure?* This field is required.

YESNO

29

How is your blood pressure controlled?eg. through diet or medication? Which medication?

30

Please provide your latest 3 blood pressure readings, and how long ago they were taken:

0/0

31

What is your highest blood pressure within the last 3 months?* This field is required.

32

Have you ever suffered a Stroke or transient ischaemic attack (TIA)?* This field is required.

YESNO

33

When did you suffer a stroke or TIA?Please upload any relevant medical documentation regarding your stroke in the evidence section at the end.

34

Do you suffer from Epilepsy or have you suffered from seizures?* This field is required.

YESNO

35

Have you ever had Rheumatic Fever or Tuberculosis?* This field is required.

YESNO

36

Do you suffer from Diabetes or Pre-diabetes (high blood sugar)?* This field is required.

YESNO

37

Please provide your latest HbA1c reading if available and the date this was taken (this can often be found within your NHS app under 'GP Health Record' > 'Test Results')Alternatively, you can upload your latest blood sugar chart in the evidence section at the end.

38

Have you ever experienced a heart attack, or do you suffer from coronary artery disease?* This field is required.

YESNO

39

Please provide further details* This field is required.

0/0

40

Do you suffer from Cardiac Arrythmias, Palpitations (irregular heart beats), or do you have an implanted cardiac defibrillator or pacemaker?* This field is required.

YesNo

41

Do you suffer from Valvular Disease? (any problem with your heart valves)* This field is required.

YESNO

42

Do you suffer from Marfans or connective tissue disease* This field is required.

YESNO

43

Do you suffer from Heart Failure?* This field is required.

YESNO

44

Do you have high cholesterol?* This field is required.

YESNO

45

Please provide your latest cholesterol readings. Alternatively you can upload these results (which can often be found within your NHS app under 'GP Health Record' > 'Test Results') in the evidence section at the end:These values will help our doctors evaluate your risk of experiencing a cardiovascular event while diving.

TOTAL CHOLESTEROL (mmol/L)

HDL CHOLESTEROL (mmol/L)

46

Do you suffer from Bleeding disorders? eg. Haemophilia, sickle cell disease* This field is required.

YESNO

47

Do you have history of any heart disease or heart surgery?* This field is required.

YESNO

48

Do you suffer from inflammatory bowel disease, intestine/bowel obstruction, hernia, or severe gastric reflux?* This field is required.

YESNO

49

Do you suffer from major depression, bipolar, psychotic disorder, personality disorder, or any other psychological problems?* This field is required.

YESNO

50

Do you have a history of panic attacks or severe anxiety?* This field is required.

YESNO

51

Do you have a learning disability or any kind of neurological impairment?* This field is required.

YESNO

52

Do you suffer from any other chronic disease/condition?* This field is required.

YESNO

53

Please provide further details of your condition(s):

54

Family History: Is there any family history of sudden cardiac death in close relatives (brothers, sisters, parents) under 50 years of age?* This field is required.

YESNO

55

If yes, please supply full details

56

Family History: Do you have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)?* This field is required.

YESNO

57

If yes, please supply full details

58

Do you suffer from or have you suffered with pains or tightness in the chest, neck, or jaw when exercising?* This field is required.

YESNO

59

Do you suffer from any conditions affecting your eyes, ears, sinuses or nose?* This field is required.

YESNO

60

Please provide further details:* This field is required.

0/0

61

Have you had any surgery within the last 6 months?In particular you must declare any head and neck surgery including eye and ear surgery.

YESNO

62

If yes, please supply full details

63

Do you suffer from or have you suffered with excessive breathlessness or wheeze when exercising?* This field is required.

YESNO

64

If yes, please supply full details

65

Do you suffer from or have you suffered with dizziness when exercising? * This field is required.

YESNO

66

If yes, please supply full details

67

Have you ever suffered from dizziness when NOT exercising?* This field is required.

YESNO

68

If yes, please supply full details

69

Have you ever collapsed or lost consciousness whilst at rest or exercising?* This field is required.

YESNO

70

If yes, please supply full details

71

Do you experience ankle swelling or puffiness in both ankles?* This field is required.

YESNO

72

If yes, please supply full details

73

Have you scuba dived before?* This field is required.

YESNO

74

Do you have the appropriate level of experience for the type and depth of dive you plan to undertake?* This field is required.

YESNO

75

Are you able to swim 200m in open water unassisted and without difficulty?

YESNO

76

Have you ever fainted?* This field is required.

YESNO

77

How much do you smoke or inhale nicotine?* This field is required.cigarettes per day

78

How much alcohol do you drink?* This field is required.units per week

79

Are there any other medical issues that we need to be aware of?* This field is required.This includes issues with drug and addition

YESNO

80

Please provide details

81

Have you ever been refused medical insurance?* This field is required.

YESNO

82

Please provide details to any questions answered yes above

83

Based on the answers you have provided, it is safer for you to have an in-person dive medical consultation with further testing, which we cannot provide.

If you choose to proceed with your submission, a doctor will still review your case and make a decision based on their discretion.

84

Your planned dives:To what depth will you be diving, and how many dives do you intend to undertake?

85

Please upload either your "Summary Care Record (SCR)" available free from your GP practice or provide screenshots of your GP medical record from your NHS app.If you do not have this to hand, you can save your progress and return to this form later. Screenshots of your NHS app must include all pages of your "GP Health Record".

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Select files to upload

Max. file size: 10.6MB

86

Please upload the results of any health tests or health checks that can help our doctors assess your fitnessAny tests within 3 years including ECGs, Spirometry, Health 360s, Cholesterol levels, screenshots from your NHS app etc. will all be valuable

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Select files to upload

Max. file size: 10.6MB

87

Please upload any custom form(s) you need completed, if requiredYou will be able to add on an additional custom form for £10 in the final payment stage, if this is required.

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Select files to upload

Max. file size: 20.4MB

88

Please attach a copy of your passport or driver's licence as proof of identification.* This field is required.We respect your data privacy and all personal information is processed confidentially and never shared.

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Max. file size: 10.6MB

89

Terms* This field is required.

I agree that upon submitting my medical consultation, I acknowledge the Terms and Privacy Policy and consent to the following: I am NOT seriously unwell with any of the following symptoms: chest pain, shortness of breath, unrelenting severe headache, worsening severe abdominal pain, loss of vision, thoughts of suicide, confusion, ongoing bleeding, unable to swallow fluids or saliva, loss of limb sensation or control, facial numbness or weakness, slurred speech. I understand the questions in the questionnaire and answered them honestly. The requested letter is solely for the individual with the provided name and details. Medical Cert is not a replacement for a doctor's visit. I confirm I do not think I need to see a medical professional in person. Medical Cert is not my primary doctor or GP, and the doctor issuing my certificate may be unable to access my NHS or regular GP medical records. Medical Cert facilitates access to private medical letters and does not issue Med3 notes, which are obtainable through your NHS GP for UK government benefits. Medical Cert is unable to process refunds once a medical letter has been written and sent to you. If my symptoms persist or I have not fully recovered, I agree to consult with my regular doctor or GP for further medical advice. I consent to having this website store my submitted information so they can respond to my inquiry.

90

Disclaimer* This field is required.

I agree to the following disclaimer: Any medical certificate is void if it is later discovered that any information has been falsely disclosed or deliberately withheld. Please be advised that the medical certificate does not guarantee fitness for an event, but represents the considered opinion of the Doctor with all the information available at the time. You agree to absolve Medical Cert UK, Knobel Health Limited, and our doctors of any liability for any adverse events affecting you or any other party at any point in time. It should be understood that dynamic studies of cardiac function such as cardiac echo or cardiopulmonary exercise testing provide a much more accurate assessment of cardiovascular fitness, however this type of specialist testing is not usually required for the medical certification process unless clinically indicated.

91

Dive Certificate

92

My Products* This field is required.

My Bag

1

Medical Cert Scuba Diving Medical ConsultationCertificate will state "no contraindications to participation in recreational diving"
£89.00Edit
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Additional Custom Sports FormIf you uploaded any specific forms you would like completed, add these here
£10.00Edit
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