Scuba Diving Medical Clearance Form

Scuba diving and free diving for fun necessitates adequate physical and mental health. There are a few medical disorders that can make diving dangerous, as described below. Any of these disorders should be evaluated by a physician if you have them or are predisposed to them. This Diver Medical Participant Questionnaire might help you decide if or not you need that evaluation. Consult your physician before diving if you have any concerns about your diving fitness that are not addressed on this form. If you're sick, don't go diving.

If you suspect you may have a contagious disease, avoid diving training and/or activities to protect yourself and others. On this form, the term "diving" refers to both recreational scuba diving and free diving. This form is intended to serve as an initial medical screening for new dives, but it can also be used by divers who are continuing their education. Answer all questions honestly for your own safety and the protection of others who may dive with you.

This questionnaire must be completed before enrolling in a recreational scuba diving or free diving school. Note: Women should not dive if they are pregnant or trying to become pregnant.

I've had issues with my lungs, breathing, heart, and/or blood that have interfered with my usual physical and mental function.

YesNo

Diver Medical

	Check Status
Chest surgery, heart surgery, heart valve surgery, an implantable medical device (such as a stent, pacemaker, or neurostimulator), pneumothorax, and/or chronic lung illness are all possibilities.	1
Within the last 12 months, I've had asthma, wheezing, severe allergies, hay fever, or congested airways, which have limited my physical activity/exercise.	2
I have a heart disease or sickness, such as angina, chest pain with exertion, heart failure, deep pulmonary edema, heart attack, or stroke, OR I am taking medicine for a heart ailment.	3
Have had recurrent bronchitis and are currently coughing, OR have been diagnosed with emphysema within the last 12 months.	4
In the last 30 days, I've had symptoms affecting my lungs, breathing, heart, and/or blood that have hampered my physical or mental performance.	5

I am more than 45 years old.

YesNo

Diver Medical

	Check Status
I currently smoke or use other methods to inhale nicotine.	6
My cholesterol level is high.	7
My blood pressure is quite high.	8
I've lost a close blood relative to sudden death, cardiac disease, or stroke before the age of 50, OR I have a family history of heart disease before the age of 50. (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).	9

I find it difficult to conduct moderate exercise (for example, walking 1.6 kilometers/one mile in 14 minutes or swimming 200 meters/yards without stopping), OR I have been unable to participate in a routine physical activity in the last 12 months owing to fitness or health concerns.

YesNo

My eyes, ears, and nasal passages/sinuses have all been bothering me.

YesNo

Diver Medical

	Check Status
Within the last six months, you've had sinus surgery.	10
Ear disease or surgery, hearing loss, or balance issues are all possibilities.	11
In the last 12 months, you've had recurrent sinusitis.	12
Within the last three months, you've had eye surgery.	13

I've undergone surgery within the last 12 months, or I'm having issues from a previous procedure.

YesNo

I've passed out, had migraine headaches, seizures, a stroke, a serious head injury, or have a chronic neurologic injury or condition.

YesNo

Diver Medical

	Check Status
Within the last five years, you've had a head injury that resulted in a loss of consciousness.	14
Neurologic damage or disease that persists.	15
Recurring migraine headaches within the past 12 months, or take medications to prevent them.	16
Within the last 5 years, you've had blackouts or faintings (complete or partial loss of consciousness).	17
Take drugs to prevent epilepsy, seizures, or convulsions if you have them.	18

I am now receiving treatment (or have received treatment in the previous five years) for psychological issues, personality disorder, panic attacks, or a drug or alcohol addiction; or I have been diagnosed with a learning or developmental disability.

YesNo

Diver Medical

	Check Status
Behavioral health refers to mental or psychological issues that require medical or psychiatric intervention.	19
Major depression, suicidal ideation, panic attacks, and uncontrolled bipolar disorder all necessitate medication and mental care.	20
You've been diagnosed with a mental illness or a learning/developmental problem that necessitates continuing treatment or specific accommodations.	21
Within the last five years, you've had a drug or alcohol addiction that necessitated treatment.	22

Back issues, hernias, ulcers, and diabetes have all been a part of my life.

YesNo

Diver Medical

	Check Status
In the last six months, I've had recurring back difficulties that have limited my daily activities. Within the last 12 months, you've had back or spinal surgery.	23
Diabetes, whether controlled by medication or diet, OR gestational diabetes within the previous 12 months.	24
My physical abilities are limited due to an untreated hernia.	25
Ulcers that are active or untreated, troublesome wounds, or ulcer surgery performed within the last 6 months.	26

I've had stomach or bowel issues in the past, including diarrhea.

YesNo

Diver Medical

	Check Status
I had ostomy surgery and am unable to swim or engage in physical activities due to my medical condition.	27
Within the last seven days, you've experienced dehydration that necessitated medical attention.	28
Within the last 6 months, you had active or untreated stomach or intestinal ulcers, or you had ulcer surgery.	29
Heartburn, regurgitation, or gastroesophageal reflux disease are all symptoms of gastroesophageal reflux disease (GERD). Crohn's disease or ulcerative colitis that is active or uncontrolled.	30
Within the last 12 months, you've had bariatric surgery.	31

I'm on a prescription medication (save for birth control and anti-malarial meds other than mefloquine).

YesNo

Participant Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

A medical evaluation is not required if you replied NO to all ten questions above. Please read the participation statement below and sign and date it if you agree.

Participant Statement: I have answered all questions truthfully and realize that I am responsible for any consequences that may arise as a result of any questions I may have answered incorrectly or for my omission to reveal any current or previous health issues.

If you answered YES to any of the questions on page 2 OR to any of the questions on page 3, please read the statement above and sign and date it, as well as take all three pages of this form (Participant Questionnaire and Physician's Evaluation Form) to your physician for a medical evaluation. Your physician must give you permission to participate in a diving course.

Participant Signature

Date Signed

Date

Choose one.

Approved – I have found no factors that make recreational scuba diving or freediving incompatible.Not approved - I've discovered situations that make recreational scuba diving or free diving impossible.

Authority Signature

Scuba Diving Medical Clearance Form

Contact Information

Participant Signature

Evaluation Result