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Diver medical report

Health questionnaire for recreational diving practice

Diving requires good physical and mental health. There are some medical conditions that can be dangerous during diving practice, which are listed below. Those who have or are predisposed to any of these conditions should be evaluated by a physician. This Diver Medical Questionnaire provides a basis for determining whether you should seek that evaluation. If you have any concerns about your fitness for diving that are not represented in this form, consult with your doctor before diving. References to "diving" in this form encompass 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 that of others who may dive with you, answer all questions honestly.

Instructions

Complete this questionnaire as a prerequisite for freediving or scuba diving.
Note for women: If you are pregnant, or trying to become pregnant, DO NOT DIVE.
1
I have had problems with my lungs/breathing, heart or blood.
Yes
No
I have / have had:
Chest surgery, heart surgery, heart valve surgery, stent placement or pneumothorax (collapsed lung).
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways in the last 12 months that limit my physical activity or exercise.
Yes
No
A problem or disease involving my heart such as: angina, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy or stroke or I am taking medication for any heart condition.
Yes
No
Recurrent bronchitis and persistent cough in the last 12 months or I have been diagnosed with emphysema.
Yes
No
2
I am over 45 years old.
Yes
No
I am over 45 years old and:
I currently smoke or inhale nicotine by other means.
Yes
No
I have high cholesterol.
Yes
No
I have high blood pressure.
Yes
No
I have had a family member (1st or 2nd degree blood relative) 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).
Yes
No
3
I struggle to perform moderate exercise (for example, walk 1.6 kilometers/one mile in 14 minutes or swim 200 meters without resting), or I have been unable to participate in normal physical activity due to fitness or health reasons in the last 12 months.
Yes
No
4
I have had problems with my eyes, ears or nasal passages/sinuses.
Yes
No
I have / have had:
Sinus surgery in the last 6 months.
Yes
No
Ear diseases or ear surgery, hearing loss or balance disturbances.
Yes
No
Recurrent sinusitis in the last 12 months.
Yes
No
Eye surgery in the last 3 months.
Yes
No
5
I have had surgery in the last 12 months or have ongoing problems related to previous surgery.
Yes
No
6
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury or suffered from persistent neurological injury or disease.
Yes
No
I have / have had:
Head injury with loss of consciousness in the last 5 years.
Yes
No
Persistent neurological injuries or diseases.
Yes
No
Recurrent migraine headaches in the last 12 months or I take medication to prevent them.
Yes
No
Fainting or blackouts (total/partial loss of consciousness) in the last 5 years.
Yes
No
Epilepsy, convulsions or seizures or I take medication to prevent them.
Yes
No
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 disability.
Yes
No
I have / have had:
Behavioral health, mental or psychological problems requiring medical or psychiatric treatment.
Yes
No
Major depression, suicidal tendencies, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Yes
No
I have been diagnosed with a mental health condition or learning or developmental disorder requiring ongoing care.
Yes
No
Drug or alcohol addiction requiring treatment in the last 5 years.
Yes
No
8
I have had back problems, hernia, ulcers or diabetes.
Yes
No
I have / have had:
Recurrent back problems in the last 6 months that limit my daily activity.
Yes
No
Back or spinal surgery in the last 12 months.
Yes
No
Diabetes, either controlled by insulin or diet or gestational diabetes in the last 12 months.
Yes
No
An uncorrected hernia that limits my physical abilities.
Yes
No
Active or untreated ulcers, problem wounds or ulcer surgery in the last 6 months.
Yes
No
9
I have had stomach or intestinal problems, including recent diarrhea.
Yes
No
I have:
Ostomy surgery and I do not have medical clearance to swim or participate in physical activity.
Yes
No
Dehydration requiring medical intervention in the last 7 days.
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.
Yes
No
Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).
Yes
No
Active or uncontrolled ulcerative colitis or Crohn’s disease.
Yes
No
Bariatric surgery in the last 12 months.
Yes
No
10
I am taking prescription medications (with the exception of birth control or antimalarial drugs).
Yes
No

Participant Signature

Please read and accept the participant statement below with your signature.
Participant Statement:
Participant signature
(If under legal age, the signature of a parent/guardian of the participant is required)
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