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MEDICAL
STATEMENT
Participant
record (Confidential Information)
Please read carefully before slgnlng.
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 (Instructor) _______________________________________________________________________
and (Facilitiy) ________________________________________________________________________
located in the city of ________________________________
state/province of _____________________
Read this statement prior to signing
it. You must complete this Medical Statement, which includes
the medical questionnaire section, to enroll in the scuba
training program. If you are a minor, you must have
this Statement signed by a parent or guardian.
Diving Is an exciting and demanding activity. When performed
correctly, applying correct techniques, it is relatively
safe. When established safety procedures are not followed,
however, there are increased risks.
To scuba dive safely., you should 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 coronary disease, a current
cold or congestion, epilepsy, a severe medical problem
or who is under the influence of alcohol or drugs should
not dive. If you have asthma, heart disease, other chronic
medical conditions or you are taking medications on a
regular basis, you should consult your doctor and the
instructor before participating in this program, and on
a regular basis thereafter upon completion. You will also
learn from the instructor the important safety rules regarding
breathing and equalization white 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 Questionnaire section, review
them with your instructor before signing.
Divers Medical Questionnaire.
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 prior to engaging
in dive activities.
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 an RSTC 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?
_____ Are you presently
taking prescription medications? (with the exception of
birth control or anti-malarial)
_____ Are you over
45 years of age and can answer YES to one or more of the
following?
- currently smoke a pipe, cigars
or cigarettes
- have a high cholesterol level
- have a family history of heart
attack or stroke
- are currently receiving medical
care
- high blood pressure
- diabetes mellitus, even if controlled
by diet alone
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)?
_____ Other chest disease or chest
surgery?
_____ Behavioral health, mental
or psychological problems (Panic attack, fear of closed
or open spaces)?
_____ Epilepsy, seizures, convulsions
or take medications to prevent them?
_____Recurring complicated migraine
headaches or take medications to prevent them?
_____ Blackouts or fainting (full/partial
loss of consciousness)?
_____ Frequent or severe suffering
from motion sickness (seasick, carsick, etc.)?
_____ Dysentery or dehydration
requiring medical intervention?
_____Any dive accidents or decompression
sickness?
_____ Inability to perform moderate
exercise (example: walk 1.6 km/one mile within 12 mins.)?
_____ Head injury with loss of consciousness
in the past five years?
_____Recurrent back problems?
_____ Back or spinal surgery?
_____ Diabetes?
_____ Back, arm or leg problems
following surgery, injury or fracture?
_____ High blood pressure or take
medicine to control blood pressure?
_____ Heart disease?
_____ Heart attack?
_____ Angina, heart surgery or blood
vessel surgery?
_____ Sinus surgery?
_____ Ear disease or surgery, hearing
loss or problems with balance?
_____ Recurrent ear problems?
_____ Bleeding or other blood disorders?
_____ Hemia?
_____ Ulcers or ulcer surgery ?
_____ A colostomy or ileostomy?
_____ Recreational drug use or treatment
for, or alcoholism in the past five years?
The Information I have provided
about my medical history is accurate to the best of my
knowledge. I agree to accept responsibility for omissions
regarding my failure to disclose any existing or past
health condition.
__________________________ _____________ ___________________________
_____________
Sgnature Date Signature
of Parent or Guardian Date
STUDENT
Please print legibly.
First Name_____________________Initial _______________Last
Name_______________________________
Birth Date (day/month/year) ________________________
Age__________
Mailing Address_____________________________________________________________________________
City ______________________________
State/Province/Region_______________________________________
Country________________________________________
Zip/Postal Code _______________________________
Home Phone {
) ____________________________Business Phone (
)_________________________
Email __________________________________________FAX_________________________________________
Name and address of your family
physician
Physician ______________________________________Clinic/Hospital_________________________________
Address____________________________________________________________________________________
Date of last physical examination____________________
Name of examiner ________________________________Clinic/Hospital
Address ___________________________
Phone (
)_______________________________ Email __________________________________________
Were you ever required to have
a physical for diving? ______(Yes or No ) If so, when?___________________________
PHYSICIAN
This person applying for training
or is presently certified to engage in scuba (self-contained
underwater breathing apparatus) diving. Your opinion of
the applicant's medical fitness for scuba diving is requested.
There are guidelines attached for your information and
reference.
Physician's Impression
__ I find no medical conditions
that I consider incompatible with diving.
__ I am unable to recommend this
Individual for diving.
Remarks ______________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________ ____________________________
Physician's Signature or
Legal Representative of Medical Practitioner Date
(Day/Month/Year)
Physician __________________________________Clinic/Hospital
_________________________________________
Address __________________________________________________________________________________________
Phone (
) ____________________________ Email _______________________________________________
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