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 pre-existing condition that may affect your safety while diving and you must seek the advice of your physician.
Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES.
• currently smoke a pipe, cigars, or cigarettes• have a high cholesterol level• have a family history of heart attacks or strokes• are currently receiving medical care• high blood pressure• diabetes mellitus, even if controlled by a diet alone
(collapsed lung)
(panic attack, fear of closed or open spaces)
(full/partial loss of consciousness)
(seasick, carsick, etc.)
(example: walk 1.6 km/one mile within 12 mins.)
