• Dive Medical / Offshore Work Risk Assessment

    The Occupational and Diving Medicine Centre

  • This questionnaire will only be used for purpose of assessing fitness to dive/work offshore. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected FILLED copy will be sent to you after submission. Please print a copy to bring to clinic.

  • Date of Birth
     / /
    2 digit day, 2 digit month, 4 digit year
  • Gender
  • Type of Dive
  • Breathing Gas used
  • Is this your first time doing a Dive Medical?
  • Frequency of Physical Activity
  • Have you been a smoker in the past?
  • Do you drink alcohol?

  • SECTION B

  • Have you ever had, or do you now have or suffer from any of the following:
    Rows
  • Blood Group
  • Tetanus Vaccination*
  • Hepatitis B Vaccination*

  • SECTION C

  • Trained in
  • The above answers were verified with a logbook.

  • SECTION D

  • Have you ever suffered from:
    Rows
  • Declaration
  • Date
     / /
    2 digit day, 2 digit month, 4 digit year
  • Date of Consultation
     - -
    2 digit day, 2 digit month, 4 digit year
  • Time
  • Visual Acuity
    Rows
  • Colour Perception (Ishihara Chart)
  • Exercise Tolerance Step Test
  • Above tests conducted by:
  • General Appearance
  • Systemic Review
    Rows
  • Tendon Reflexes
    Rows
  • Peripheral Pulses
  • Sharpened Rhomberg's (60s)
  • Summary of Findings/Investigations
    Rows
  • Other Tests

  • Medical Fitness Recommendations

  • Recreational Diving Certificate required
  • Type of Diving/Work
  • Certification
  • Presence of medical condition that would place the abovementioned at an increased risk of performing his/her work duties. The abovementioned has been informed of the risk:
  • Validity

  • Dr Gregory Chan Chung Tsing, PPA(G), PP

    MBBS, MMED Occup Med, GDip Geriatric Med, GDip FP Derm, Cert DHM (Adelaide, Toronto), DWD (All hazards)

    Senior Specialist Physician, Occupational Medicine

    MCR: M06367C

  • Date of Certification
     / /
    2 digit day, 2 digit month, 4 digit year
  • Declaration by Candidate
  • Date
     / /
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: