![](media/image1.jpeg){width="0.5048611111111111in"
height="0.8611111111111112in"}**Perry Institute for Marine Science**

**Medical Evaluation of Fitness for SCUBA Diving**

To the examining physician:

The applicant noted below requires a medical examination to assess
his/her fitness to SCUBA dive at the Perry Institute for Marine Science
(PIMS) in the Bahamas. If you have any questions regarding the
evaluation, please contact the Diving Safety Officer at PIMS for
references in diving medicine or a list of physicians with expertise in
diving medicine. Hyperbaric exposure can be strenuous and hazardous.
Special risk is present if the middle ear, sinuses, or lung segments do
not readily equalize to air pressure changes. Most fatalities involve
deficiencies in prudence, judgement, emotional stability or physical
fitness. Please consult the following list of conditions that usually
restrict candidates from diving: (Adapted from Bove, 1998)

-   Abnormalities of the tympanic membrane, such as perforation,
    presence of monomeric membrane, or inability to autoinflate the
    middle ears

-   Vertigo, including Meniere's Disease

-   Stapedectomy or middle ear reconstructive surgery

-   Recent ocular surgery

-   Psychiatric disorders including claustrophobia, suicidal ideation,
    psychosis, anxiety states, and untreated depression

-   Substance abuse, including alcohol

-   Episodic loss of consciousness

-   History of seizure

-   History of stroke or a fixed neurological deficit

-   Recurring neurological disorders, including transient ischemic
    attacks

-   History of intercranial aneurism, or other vascular malformation or
    intercranial hemorrhage

-   History of neurological decompression illness with residual deficit

-   Head injury with sequelae

-   Hematologic disorders including coagulopathies

-   Evidence of coronary artery disease or high risk for coronary artery
    disease

-   Atrial septal defects

-   Significant valvular heart disease -- isolated mitral valve prolapse
    is not disqualifying

-   Significant cardiac rhythm or conduction abnormalities

-   Implanted cardiac pacemakers and cardiac defibrillators (ICD)

-   Severe hypertension

-   History of spontaneous or traumatic pneumothorax

-   Asthma

-   Chronic pulmonary disease, including radiographic evidence of
    pulmonary blebs, bullae, or cysts

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-   Diabetes mellitus

-   Pregnancy

+-----------------------+----------+----------+------+---+----------+
| **Applicant's Name    |          | **Age    |      | * |          |
| (print):     **       |          | :     ** |      | * |          |
|                       |          |          |      | B |          |
|                       |          |          |      | i |          |
|                       |          |          |      | r |          |
|                       |          |          |      | t |          |
|                       |          |          |      | h |          |
|                       |          |          |      | D |          |
|                       |          |          |      | a |          |
|                       |          |          |      | t |          |
|                       |          |          |      | e |          |
|                       |          |          |      | : |          |
|                       |          |          |      |   |          |
|                       |          |          |      |   |          |
|                       |          |          |      |   |          |
|                       |          |          |      |   |          |
|                       |          |          |      |   |          |
|                       |          |          |      | * |          |
|                       |          |          |      | * |          |
+-----------------------+----------+----------+------+---+----------+
| # Required tests      | **Init.  | **Re     | **I  |   | **Re     |
|                       | exam ≤   | -exam^1^ | nit. |   | -exam^1^ |
|                       | 40years  | ≤        | exam |   | \>       |
|                       | old**    | 40years  | \>   |   | 40years  |
|                       |          | old**    | 40y  |   | old**    |
|                       |          |          | ears |   |          |
|                       |          |          | o    |   |          |
|                       |          |          | ld** |   |          |
+-----------------------+----------+----------+------+---+----------+
| Medical history       | -   yes  | -   yes  | -    |   | -   yes  |
|                       |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Complete physical     | -   yes  | -   yes  | -    |   | -   yes  |
| exam                  |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Assessment of         |          |          | -    |   | -   yes  |
| coronary artery       |          |          |  yes |   |          |
| disease               |          |          |      |   |          |
|                       |          |          |      |   |          |
| using                 |          |          |      |   |          |
| Multiple-Risk-Factor  |          |          |      |   |          |
| Assessment^2^         |          |          |      |   |          |
+-----------------------+----------+----------+------+---+----------+
| Resting EKG           |          |          | -    |   | -   yes  |
|                       |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Chest X-ray           | -   yes  |          | -    |   |          |
|                       |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Spirometry            | -   yes  |          | -    |   |          |
|                       |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Urinalysis            | -   yes  | -   yes  | -    |   | -   yes  |
|                       |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Hematocrit or         | -   yes  | -   yes  | -    |   | -   yes  |
| Hemoglobin            |          |          |  yes |   |          |
+-----------------------+----------+----------+------+---+----------+
| Further tests deemed  | -   yes  | -   yes  | -    |   | -   yes  |
| necessary by          |          |          |  yes |   |          |
| physician             |          |          |      |   |          |
|                       |          |          |      |   |          |
| (Exercise stress      |          |          |      |   |          |
| testing^3^ may be     |          |          |      |   |          |
| indicated             |          |          |      |   |          |
|                       |          |          |      |   |          |
| based on risk factor  |          |          |      |   |          |
| assessment)           |          |          |      |   |          |
+-----------------------+----------+----------+------+---+----------+

^1^ Re-exam required: every 5 years for ≤40 year-olds; every three years
for \>40 to ≤60 year-olds; every two years \>60 year-olds

^2^ "Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor
Assessment Equations." Grundy et al. 1999. AHA/ACC Scientific Statement.
www.acc.org/clinical/consensus/risk/risk1999.pdf

^3^ Gibbons BJ, et al. ACC/AHA Guidelines for Exercise Testing. A report
of the American College of Cardiology/American Heart Association Task
Force on Practical Guidelines (Committee on Exercise Testing).

Journal of the American College of Cardiology. 30:260-311. 1997.
www.acc.org/clinical/guidelines/exercise/exercise.pdf

I (the examining physician) have examined the applicant and attest with
my signature that (please check appropriate box):

 I find no defects that I consider incompatible with SCUBA diving or
other hyperbaric exposure. Applicant is medically APPROVED.

 I find defects that I believe constitute unacceptable risk to his/her
health and safety during SCUBA

diving or other hyperbaric exposure. Applicant is medically REJECTED.

Physician's
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date of Examination:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Address or stamp:

Physician's notes:

Applicant's Release of Medical Information

> I authorize the release of this form and other pertinent medical
> documents to the PIMS Diving Safety Officer and/or Diving Control
> Board or designee with the understanding that it/they will be kept
> confidential.

Applicant's Name (print then
sign):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_