Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which canbe hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by aphysician. 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 feelingill, 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.
Yes
Go tobox A

1

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

2

I am over 45 years of age.

Yes
Go tobox B

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.

Yes

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

Yes
Go tobox C

5

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

Yes

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

Yes
Go tobox D

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 or developmentaldisability.

Yes

7Go tobox ENo

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

Go tobox FNo

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

Yes
Go tobox G

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

Yes

NoNo
*NoNo
*

NoNoYesNo*

No

Participant Signature

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

Participant Signature (or, if a minor, participant‘s parent/guardian signature required.

Date (dd/mm/yyyy)

Participant Name (Print)

Birthdate (dd/mm/yyyy)

Instructor Name (Print)

Facility Name (Print)* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to thestatement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the
Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires yourphysician’s approval.

Version date: 2022-02-01

1 of 3© 2020Participant Name

Birthdate(Print)

Date (dd/mm/yyyy)

Diver Medical | Participant Questionnaire Continued
BOX A – I HAVE/HAVE HAD:
Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax,and/or chronic lung disease.

Yes

*

No

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.

Yes

*

No

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke,
OR am taking medication for any heart condition.

Yes

*

No

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.

Yes

*

No

Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.

Yes

*

No

I currently smoke or inhale nicotine by other means.

Yes

*

No

I have a high cholesterol level.

Yes

*

No

I have high blood pressure.

Yes

*

No

I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease
before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Yes

*

No

Sinus surgery within the last 6 months.

Yes

*

No

Ear disease or ear surgery, hearing loss, or problems with balance.

Yes

*

No

Recurrent sinusitis within the past 12 months.

Yes

*

No

Eye surgery within the past 3 months.

Yes

*

No

Head injury with loss of consciousness within the past 5 years.

Yes

*

No

Persistent neurologic injury or disease.

Yes

*

No

Recurring migraine headaches within the past 12 months, or take medications to prevent them.

Yes*

NoBlackouts or fainting (full/partial loss of consciousness) within the last 5 years.

Yes

*

No

Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Yes

*

No

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Yes

*

No

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.

Yes

*

No

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.

Yes*

NoAn addiction to drugs or alcohol requiring treatment within the last 5 years.

Yes

*

No

Recurrent back problems in the last 6 months that limit my everyday activity.

Yes

*

No

Back or spinal surgery within the last 12 months.

Yes

*

No

Diabetes, either drug or diet controlled, OR gestational diabetes within 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 within the last 6 months.

Yes

*

No

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.

Yes

*

No

Dehydration requiring medical intervention within the last 7 days.

Yes

*

No

Active or untreated stomach or intestinal ulcers or ulcer surgery within 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 within the last 12 months.

Yes

*

No

BOX B – I AM OVER 45 YEARS OF AGE AND:BOX C – I HAVE/HAVE HAD:

BOX D – I HAVE/HAVE HAD:

BOX E – I HAVE/HAVE HAD:

BOX F – I HAVE/HAVE HAD:

BOX G – I HAVE HAD:

*Physician’s medical evaluation required (see page 1).

2 of 3© 2020Diver Medical | Medical Examiner’s Evaluation Form
BirthdateParticipant Name

Date (dd/mm/yyyy)(Print)

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving
training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas relevant to your patient as part of your evaluation.

Evaluation Result
Approved – I find no conditions that I consider incompatible with recreational scuba diving or freediving.
Not approved – I find conditions that I consider incompatible with recreational scuba diving or freediving.

Date (dd/mm/yyyy)

Signature of certified medical doctor or other legally certified medical provider

Medical Examiner’s Name(Print)

Clinical Degrees/Credentials

Clinic/Hospital

Address

Phone

Email

Physician/Clinic Stamp (optional)

Created by the Diver Medical Screen Committee in association with thefollowing bodies:
The Undersea & Hyperbaric Medical Society
DAN (US)DAN Europe
Hyperbaric Medicine Division, University of California, San Diego© DMSC 2020

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