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Diver's Medical Questionnaire & Information form
Please fill out your medical details and acknowledge the liability terms to participate.
Full Name
*
First Name / Family Name
Date of Birth
*
-
Month
-
Day
Year
Date
Are you 18 years of age or older?
Yes
No, I am under 18 years old.
If you are under the age of 18 years, Parental authorization form is required.
Please click
here
.
Email Address and Phone Number
*
example@example.com
Please enter a valid phone number.
Emergency Contact Name
First Name / Family Name
Emergency Contact Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a certified diver?
*
Yes, I am certified.
No, I don't have a diver certification
Certification Agency
選択してください
PADI
SSI
CMAS
BSAC
NAUI
Other
Certification Level
*
選択してください
Junior Open Water Diver
Open Water Diver
Advanced Open Water Diver
Rescue Diver
Divemaster
Instructor or above
Number of Dives
*
How many dives have you done?
Last Dive
*
When was your last dive?
Number of Dives
*
How many dives have you done?
Which equipment will you bring?
*
Mask
Fins
Wetsuit
BCD
Regulator
I need to rent all.
I will bring all of them. I don't need rental equipment.
Your Height
*
Please fill this out if you wish to rent equipment.
Your weight
*
Please fill this out if you wish to rent equipment.
Fin size
*
Please fill in if you need to rent fins.
Are you able to go up on the boat with ALL THE EQUIPMENT/TANK ON using a ladder?
*
Yes, no problem.
No, I need to take them off at the surface.
Medical Questionnaire
Have you ever had or do you currently have any of the following conditions?
*
I am over 45 years of age
Asthma or breathing problems
Heart disease
Lung disease
Diabetes
Epilepsy or seizures / Blackouts or fainting
High blood pressure
Ear surgery or ear problems or eye surgery
Back/spinal problems, hernia, knee, hips problem.
Stomach or intestine problems, including recent diarrhea.
Recent surgery (within the last 12 months) or ongoing problems related to past surgery
Taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).
Pregnancy (This includes the possibility of pregnancy.)
Psychological problems, personality disorder, panic attacks, or addiction to drugs or alcohol.
Head injury, persistent neurologic injury or disease, recurring migraine headaches.
I struggle to perform moderate exercise (for example: walk 1.6 km / 1 mile in 14 minutes or swim 200 meters/yards without resting).
None of the above
(I am over 45, and) I have/have had:
I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
None of the above
If you have "YES (✔️)" to any medical question above, a physician approval is required before participating in diving activities. (You are over 45, but have no "Yes✔️" answer to any of the following questions of (over 45, and), a physician's approval is not required.)
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Participant Statement and Signature
If you checked "Non of the above", a medical evaluation is not required. Please read and agree to the participant statements and terms & conditions below by signing and dating it.
Signature
*
Date
*
-
Month
-
Day
Year
MM/DD/YYYY
Please write down anything you would like to tell us in advance, or any requests or preferences you have.
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