Medical Report - Diving Lanzarote

Diver's Medical Report

Participant Questionnaire (confidential)

Diving requires good physical and mental health. There are some medical conditions that can be dangerous while scuba diving, which are listed below.

Those who have or are predisposed to any of these conditions should be evaluated by a physician. This Diver's Physician Questionnaire provides a basis for determining whether you should seek such an evaluation.

If you have any concerns about your diving fitness and they are not represented on this form, consult your physician before diving. References to "scuba diving" in this form cover both Recreational scuba diving and freediving. This form is designed primarily as an initial medical examination for new divers, but is also appropriate for divers receiving continuing education.

For your safety and the safety of others who may dive with you, answer all questions honestly.

- Step 1 of 2

Instructions

Complete este cuestionario como requisito previo para el entrenamiento de apnea o de buceo con equipo autónomo.
Para las mujeres: Si usted está embarazada, o intenta quedar embarazada, no bucee.

1) I have had problems with my lungs, breathing, heart and/or blood that affect my normal physical or mental performance.

Yes-Go to Table A
No

2) I am over 45 years old.

Yes-Go to Table B
No

3) I find it difficult to engage in moderate exercise (e.g., walking 1.6 kilometers/one mile in 12 minutes or swimming 200 meters/yards without rest), OR I have been unable to participate in normal physical activity due to fitness or health reasons in the past 12 months.

4) I have had problems with my eyes, ears, or nostrils/sinuses.

Yes-Go to Table C
No

5) I have had surgery within the last 12 months, OR I have ongoing problems related to a previous surgery.

6) I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffered from persistent neurological injury or disease.

Yes-Go to Table D
No

7) I have had psychological problems (or have received psychological treatment in the last 5 years), been diagnosed with a learning disability, personality disorder, panic attacks or a drug or alcohol addiction, been diagnosed with a learning or developmental disability.

Yes-Go to Table E
No

8) I have had back problems, hernia, ulcers or diabetes.

Yes-Go to Table F
No

9) I have had stomach or intestinal problems, including recent diarrhea.

Yes-Go to Table G
No

10) I am taking prescription medications (with the exception of contraceptives or antimalarial drugs other than Lariam-mefloquine).

Participant's Signature

If you answered NO to the above 10 questions, a medical evaluation is not required. Please read and accept the participant statement below with the date and your signature.

Participant's Statement: I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions

Design

Signature of participant (or, if minor, signature of participant's parent/guardian is required). *

Signature of participant (or, if a minor, the signature of the participant's parent/guardian is required).

Date (dd/mm/yyyy) *//

Date (dd/mm/yyyy)

Date of Birth (dd/mm/yyyy) *//

Date of Birth (dd/mm/yyyy)

Name and Surname * Names and Surname * Names and Surnames * Names and Surnames * Names and Surnames

Participant's First and Last Name (Capital Letters)

Design

Name of the Dive Center (capital letters) *

Name of the Dive Center (Capital Letters)

Instructor's name (Capital letters) *

Instructor's name (Capital letters)

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, read and accept the above statement with the date and your signature AND take the Physician Evaluation Form (page 3) to your physician. Physician Evaluation Form (page 3) to your physician for a medical evaluation.for a medical evaluation. Participation in a dive training program requires your physician's approval.

Design

Participant's name *

Participant's Name

Date of Birth * Date of Birth * Date of Birth * Date of Birth * Date of Birth * Date of Birth * Date of Birth//

Date of Birth

Diver's Medical Report | Participant Questionnaire (Confidential) Continued

BOX A - I HAVE/HAD:

Thoracic surgery, cardiac surgery, heart valve surgery, an implanted medical device (e.g., stent, pacemaker, neurostimulator), pneumothorax and/or chronic lung disease.

Asthma, wheezing, severe allergies, hay fever or congested airways in the past 12 months that limit my physical activity/exercise.

A problem or disease involving my heart such as: angina pectoris, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy or stroke, OR I am taking medication for any heart condition.

Recurrent bronchitis and persistent cough in the past 12 months, OR have been diagnosed with emphysema.

Symptoms affecting my lungs, breathing, heart and/or blood within the last 30 days that impair my physical or mental performance

BOX B - I AM OVER 45 YEARS OLD AND:

I currently smoke or inhale nicotine by other means.

I have a high cholesterol level.

I have high blood pressure.

I have had a family member (1st OR 2nd degree by blood) who died of sudden death or heart disease or stroke before age 50, OR I have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

BOX C - I HAVE/HAD:

Sinus surgery in the last 6 months.

Diseases of the ear or ear surgery, hearing loss or balance disorders.

Recurrent sinusitis in the last 12 months.

Ocular surgery in the last 3 months.

BOX D - I HAVE/HAD:

Head injury with loss of consciousness within the last 5 years.

Persistent neurological injuries or diseases.

Recurrent migraine headaches in the last 12 months, or I take medication to prevent them.

Fainting or blackouts (total/partial loss of consciousness) in the last 5 years.

Epilepsy, seizures or convulsions, OR I take medication to prevent them.

BOX E - I HAVE/HAD:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Major depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder requiring psychiatric medication/treatment.

I have been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.

A drug or alcohol addiction requiring treatment within the last 5 years.

BOX F - I HAVE/HAD:

Recurrent back problems in the last 6 months that limit my daily activity.

Back or spine surgery in the last 12 months.

Diabetes, either controlled by medication or diet, OR gestational diabetes within the last 12 months.

An uncorrected hernia that limits my physical abilities.

Active or untreated ulcers, problematic wounds or ulcer surgery within the last 6 months.

BOX G - I HAVE:

I have ostomy surgery and am not medically cleared to swim or participate in physical activity.

Dehydration requiring medical intervention in the last 7 days.

Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.

Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).

Active or uncontrolled ulcerative colitis or Crohn's disease.

Bariatric surgery in the last 12 months.

*A medical evaluation by a physician is required (see page 1).

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