Dive Addicts

Diver Medical | Participant Questionnaire


Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/ or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

I am signing this waiver on behalf of:  

If signing on behalf of a minor:

Minor First Name:  

Minor Last Name:  

First Name:

Last Name:

Phone Number:

Date of Birth (please spell out month):  

 

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course with Dive Addicts.

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

  1. I have had problems with my lungs/breathing, heart, blood, have had symptoms related to COVID-19, or tested positive for COVID-19.  
  2. I am over 45 years of age.  
  3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.  
  4. I have had problems with my eyes, ears, or nasal passages/sinuses.  
  5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.  
  6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.  
  7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.  
  8. I have had back problems, hernia, ulcers, or diabetes.  
  9. I have had stomach or intestine problems, including recent diarrhea.  
  10. I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).  

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to any question above, you will need to complete page 2 on this form: Participant Questionnaire and the Physician’s Evaluation Form

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement below by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

 

Participant Statement: I have answered all questions honestly, and 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.

 

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Document name: Diver Medical | Participant Questionnaire
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March 2, 2022 2:06 pm MDTDiver Medical | Participant Questionnaire Uploaded by Joshua Thornton - info@diveaddicts.com IP 174.52.192.216
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