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 preexisting condition that may affect your safety
while diving and you must seek the advice of your physician prior to engaging in dive activities.
If you answer YES to any of these items, we must request that you consult with a physician prior to participating in a dive course.
_____ Could you be pregnant, or are you attempting to become pregnant?
_____ Are you presently taking prescription medications? (with the exception of
birth control or anti-malarial)
_____ Are you over 45 years of age and can answer YES to one or more of the
currently smoke a pipe, cigars or cigarettes
have a high cholesterol level
have a family history of heart attack or stroke
are currently receiving medical care
high blood pressure
diabetes mellitus, even if controlled by diet alone
Have you ever had or do you currently have
_____ Asthma, or wheezing with breathing, or wheezing with exercise?
_____ Frequent or severe attacks of hayfever or allergy?
_____ Frequent colds, sinusitis or bronchitis?
_____ Any form of lung disease?
_____ Pneumothorax (collapsed lung)?
_____ Other chest disease or chest surgery?
_____ Behavioral health, mental or psychological problems (Panic attack, fear of
closed or open spaces)?
_____ Epilepsy, seizures, convulsions or take medications to prevent them?
_____ Recurring complicated migraine headaches or take medications to prevent
_____ Blackouts or fainting (full/partial loss of consciousness)?
_____ Frequent or severe suffering from motion sickness (seasick, carsick,
_____ Dysentery or dehydration requiring medical intervention?
_____ Any dive accidents or decompression sickness?
_____ Inability to perform moderate exercise (example: walk 1.6 km/one mile
within 12 mins.)?
_____ Head injury with loss of consciousness in the past five years?
_____ Recurrent back problems?
_____ Back or spinal surgery?
_____ Back, arm or leg problems following surgery, injury or fracture?
_____ High blood pressure or take medicine to control blood pressure?
_____ Heart disease?
_____ Heart attack?
_____ Angina, heart surgery or blood vessel surgery?
_____ Sinus surgery?
_____ Ear disease or surgery, hearing loss or problems with balance?
_____ Recurrent ear problems?
_____ Bleeding or other blood disorders?
_____ Ulcers or ulcer surgery ?
_____ A colostomy or ileostomy?
_____ Recreational drug use or treatment for, or alcoholism in the past five
Please ask us if you need more information on this questionnaire