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To the Participant:  The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting 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. Your instructor will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to your physician.

_____ Could you be pregnant or are you attempting to become pregnant? 
_____ Do you regularly take prescription or nonprescription 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 hayfever 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 take medications to prevent them?
_____ Recurring migraine headaches or take medications to prevent them?
_____ History of blackouts or fainting (full/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: walk one mile within 12 minutes)?
_____ History of high blood pressure or take medicine 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?

Please read carefully before signing.
This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by _________________________________________ and Instructor _______________________________________ located in the Facility city of __________________ and state of ____________.  Read and discuss this statement prior to signing it. You must complete this Medical Statement, which includes the medical-history section, to enroll in the scuba-training program. If you are a minor, you must have this Statement signed by a parent.  Diving is an exciting and demanding activity. When per-formed correctly, applying correct techniques, it is very safe.  When established safety procedures are not followed, however, there are dangers. To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor and the instructor before participation in this program.  You will also need to learn from the instructor the important safety rules regarding breathing and equalization while scuba diving.  Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.  If you have any additional questions regarding this Medical Statement or the Medical History section, review them with your instructor before signing. 
The information I have provided about my medical history is accurate to the best of my knowledge.

_______________________________________________________________________________________ _______

Participant’s Signature                                                                                         Date (day/month/year)
_______________________________________________________________________________________ ________
Signatures of Parent or Guardian (where applicable)                                        Date (day/month/year)


This page last updated on 11/22/2007 from our Windwardside office.

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