||Before Scuba Diving, we need you to be aware of the following information, which has been supplied by PADI. A document containing this information will be provided to you on the day you do your dive and you will need to complete it and sign it prior to completing your dive.
To the Diver:
The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving and you must seek the advice of your physician.
Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving.
- Could you be pregnant or are you attempting to become pregnant?
- Do you regularly take prescription or non-prescription medications? (with the exception of birth control)
- Are you over 45 years of age and have one or more of the following:
- currently smoke a pipe, cigars or cigarettes?
- have a high cholesterol level?
- have a family history of heart attacks or strokes?
Have you ever had or do you currently have...
- Asthma, or wheezing with breathing, or wheezing with exercise?
- Frequent or severe attacks of hay fever or allergy?
- Frequent colds, sinusitis or bronchitis?
- Any form of lung disease?
- Pneumothorax (collapsed lung?)
- History of chest surgery?
- Claustrophobia or agoraphobia (fear of closed or open spaces)?
- Behavioral health problems?
- Epilepsy, seizures, convulsions or do you take medications to prevent them?
- Recurring migraine headaches or do you take medications to prevent them?
- History of blackouts or fainting (full or partial loss of consciousness)?
- Do you frequently suffer from motion sickness (seasick, carsick, etc.?)
- History of diving accidents or decompression sickness?
- History of recurrent back problems?
- History of back surgery?
- History of diabetes?
- History of back, arm or leg problems following surgery, injury or fracture?
- Inability to perform moderate exercise (example: walking one mile within 12 minutes)?
- History or high blood pressure or do you take medication to control blood pressure?
- History of any heart disease?
- History of heart attacks?
- Angina or heart surgery or blood vessel surgery?
- History of ear or sinus surgery?
- History of ear disease, hearing loss or problems with balance?
- History of problems equalizing (popping) ears with airplane or mountain travel?
- History of bleeding or other blood disorders?
- History of any type of hernia?
- History of ulcers or ulcer surgery?
- History of colostomy?
- History of drug or alcohol abuse?
This information I have provided about my medical history is accurate to the best of my knowledge.
Diver Signature ________________________
Parent / Guardian Signature ____________________
Date of Signature _______________
This PADI Form is Product Number 10065 / © International PADI, Inc. 1991 - 2008