Diver Medical

Form 2 of 6 · Participant Questionnaire · about 4 minutes

  1. 1Registration
  2. 2Diver Medical
  3. 3Liability Release
  4. 4Safe Diving Practices
  5. 5Continuing Education
  6. 6Cancellation Policy

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions: complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women: if you are pregnant, or attempting to become pregnant, do not dive.

Participant

Questionnaire Answer YES or NO to every question. If you answer YES to a question with a box, please also answer the questions in that box.

1. I have had problems with my lungs/breathing, heart, blood affecting my normal physical or mental performance.

2. I am over 45 years of age.

3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.

4. I have had problems with my eyes, ears, or nasal passages/sinuses.

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

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.

8. I have had back problems, hernia, ulcers, or diabetes.

9. I have had stomach or intestine problems, including recent diarrhea.

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).

Participant Statement

I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement above by signing and dating below.

If you answered YES to questions 3, 5 or 10 above OR to any of the questions in the extra boxes, please sign and date below as well, and have a physician complete the PADI Diver Medical Physician’s Evaluation Form before you dive (ask us for a copy). Participation in a diving course in this circumstance requires your physician’s approval.

Date & signature

Your signature *
Draw with your finger, mouse or pen
Parent / guardian signature (where applicable)
Required for participants under 18

Your details go directly to Fish & Friends Diving Center and are used only for your diving activities. A signed PDF copy is emailed to you.