Medical questionnaire

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

Medical questionnaire

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