Diving Customer Record Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Are you Scuba diving or snorkeling with us? *
Please Select
Scuba Diving
Snorkeling
Diver level
Please Select
None
Open Water
Advanced Open Water
Speciality Diver
Rescue
Divemaster
Instructor
Please upload a copy of your highest certification. If you have it on hand, please show it to your Instructor.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Number of dives done so far
Do you hold Insurance that covers you for diving?
Yes
No
Dive Medical
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.
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I am over 45 years of age
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I currently smoke or inhale nicotine by other means.
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I have a high cholesterol level.
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I have high blood pressure.
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I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
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I struggle to perform moderate exercise.
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I have had problems with my eyes, ears, or nasal passages/sinuses.
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I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
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36
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
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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.
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I have had back problems, hernia, ulcers, or diabetes.
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I have had stomach or intestine problems, including recent diarrhea.
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I am taking prescription medications.
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Participant Signature (or, if a minor, participant‘s parent/guardian signature required.
Participant Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
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