CONTINUING EDUCATION STUDENT DIVER
MEDICAL DECLARATION
Please read carefully before signing.
This is a declaration in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba diving training program. Yoursignature on this statement is required for you to participate in the training offered by Pro Dive Cairns, 116 Spence Street, Cairns Qld 4870.

Participant Medical Questionnaire (must be completed within 12 Months of course commencement)
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 andothers by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving andfreediving. This form is designed for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions
honestly.
If you have any additional questions regarding this declaration or the Medical Questionnaire section, review them with your instructor before signing.
Please answer the following questions on your past and present medical history by answering YES or NO. If you are not sure, answer YES. If any of these
items apply to you, you must be assessed by a medical practitioner prior to participating in training. To undertake recreational diver training, the medical
physician must issue you with a dive medical certificate that states that you are fit to undertake recreational diver training.
_____ Could you be pregnant or are you attempting to become pregnant?

_____ Epilepsy, seizures, convulsions or take medications to prevent them?

_____ Are you presently taking prescription medications? (with the
exception of birth control or anti-malarial medication other thanmefloquine (Lariam)_____ Are you over 45 years of age AND can answer YES to one or more of
the following questions?

Currently smoke or inhale nicotine by other methodsHave high cholesterol levelHave high blood pressureHave had a close blood relative die suddenly of cardiac diseaseor stroke before the age of 50 , OR have a family history of heartdisease before the age of 50( including abnormal heart rhythms,
coronary artery disease or cardiomyopathy)
Have you ever had or do you currently have:_____ Behavioural health, mental or psychological problems requiring
medical/psychiatric treatment?
_____ Major depression, suicidal ideation, panic attacks, uncontrolled
bipolar requiring medication/psychiatric treatment?
_____ Been diagnosed with a mental health condition or alearning/developmental disorder that requires ongoing care?
_____ An addiction to drugs or alcohol requiring treatment in the last 5
years?
_____ Recurrent back problems in the last 6 months that limit my everyday
activity?

_____ Chest surgery, heart surgery, heart valve surgery, stent placement, ora pneumothorax (collapsed lung) and/or Chronic Lung disease?

_____ Back or spinal surgery in the last 12 months?

_____ Asthma, wheezing, severe allergies, hay fever or congested airways _____ Diabetes, drug or diet controlled, or gestational diabetes within thelast 12 months?

within the last 12 months that limits physical activity/exercise?

_____ A problem or illness involving my heart such as: angina, chest pain on _____ An uncorrected hernia that limits my physical activity?
exertion, heart failure, immersion pulmonary edema, heart attack or _____ Active or untreated ulcers, problem wounds, or ulcer surgery withinstroke, OR am taking medication for any heart condition
the last 6 months?
_____ Recurrent bronchitis and currently coughing within the past 12_____ Ostomy surgery and do not have medical clearance to swim ormonths, Or have been diagnosed with Emphysema?
engage in physical activity?
_____ Symptoms affecting my lungs, heart and/or blood in the last 30 days_____ Dehydration requiring medical intervention in the last 7 days?
that impair my physical or mental performance?
_____ Active or untreated stomach or intestinal ulcers or ulcer surgery_____ Sinus surgery within the last 6 months?
within the last 6 months?
_____ Ear disease or surgery, hearing loss or problems with balance?
_____ Frequent heartburn, regurgitation, or gastroesophageal reflux_____ Recurrent sinusitis within the past 12 months?
disease (GERD)?
_____ Eye surgery within the past 3 months?
_____ Active uncontrolled ulcerative colitis or Crohns disease?
_____ Head injury with loss of consciousness in the past five years?
_____ Bariatric surgery within the last 12 months?
_____ Persistent Neurologic injury or disease?
_____ I struggle to perform moderate exercise (for example, walk 1.6km in_____ Recurring migraine headaches within the past 12 months, or take14 min or swim 200M without resting), Or I have been unable tomedication to prevent them?
participate in a normal physical activity due to fitness or healthreasons in the past 12 months_____ Blackouts or fainting (full or partial loss of consciousness within the_____I have had surgery within the last 12 months, Or I have ongoinglast 5 years?
problems related to past surgery
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 Name____________________________________________Name of Parent or Guardian (if applicable)___/____/_____
Birth Date______________________
Signature____________________________/____/____

Age

Signature of participant

Date_______________________
Relationship

1 of 5___/____/____Date

STUDENT
Please print legibly.
Name____________________________________________ Birth Date ___/___/_____ Age ________
First

InitialLast

dd/mm/yyyy

Mailing Address: ____________________________________________________________________
City________________________ State/Province/Region ____________________________________Country ________________________________ Zip/Postal Code______________________________
Mobile Phone () ____________________________

Email _______________________________________PHYSICIAN
The above-named person requests your opinion of their 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 (please circle one)
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 ____/____/______
Physician’s Signature
dd/mm/yyyy
Physician:__________________________________ Specialty:__________________________
Clinic/Hospital:_________________________
Address:_________________________________________________________________________________________________________________________________________________
Phone (

) _______________________ Email ______________________________________

Physician/Clinic stamp

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Instructions to the Physician:Recreational SCUBA (Self-Contained Underwater Breathing
Apparatus) can provide recreational divers with an enjoyable
sport safer than many other activities. The risk of diving isincreased by certain physical conditions, which therelationship to diving may not be readily obvious. Thus, it isimportant to screen divers for such conditions.
The RECREATIONAL SCUBA DIVER’S PHYSICAL
EXAMINATION focuses on conditions that may put a diver atincreased risk for decompression sickness, pulmonary over
inflation syndrome with subsequent arterial gas embolizationand other conditions such as loss of consciousness, which
could lead to drowning. Additionally, the diver must be able towithstand some degree of cold stress, the physiologicaleffects of immersion and the optical effects of water and havesufficient physical and mental reserves to deal with possible
emergencies.
The history, review of systems and physical examination
should include as a minimum the points listed below. The listof conditions that might adversely affect the diver is not allinclusive, but contains the most commonly encountered
medical problems. The brief introductions should serve as analert to the nature of the risk posed by each medical problem.
The potential diver and his or her physician must weigh thepleasures to be had by diving against an increased risk ofdeath or injury due to the individual’s medical condition. As
with any recreational activity, there are no data for diving
enabling the calculation of an accurate mathematicalprobability of injury. Experience and physiological principles
only permit a qualitative assessment of relative risk.
For the purposes of this document, Severe Risk implies thatan individual is believed to be at substantially elevated risk ofdecompression sickness, pulmonary or otic barotrauma or
altered consciousness with subsequent drowning, comparedwith the general population. The consultants involved indrafting this document would generally discourage a studentwith such medical problems from diving. Relative Risk refers
to a moderate increase in risk, which in some instances may
be acceptable. To make a decision as to whether diving iscontraindicated for this category of medical problems,
physicians must base their judgement on an assessment of
the individual patient. Some medical problems which may
preclude diving are temporary in nature or responsive totreatment, allowing the student to dive safely after they haveresolved.
Diagnostic studies and specialty consultations should beobtained as indicated to determine the diver’s status. A list ofreferences is included to aid in clarifying issues that arise.
Physicians and other medical professionals of the Divers Alert
Network (DAN) associated with Duke University Health
System are available for consultation by phone +1 919 684
2948 during normal business hours. For emergency calls, 24hours 7 days a week, call +1 919 684 8111 or +1 919 684
4DAN (collect). Related organizations exist in other parts of
the world – DAN Europe in Italy +39 039605 7858, DAN
S.E.A.P. in Australia +61 3 9886 9166 and Divers Emergency
Service (DES) in Australia +61 8 8212 9242, DAN Japan +81
33590 6501 and DAN Southern Africa +27 11 242
0380. There are also a number of informative websites
offering similar advice.

NEUROLOGICAL
Neurological abnormalities affecting a diver’s ability to perform
exercise should be assessed according to the degree ofcompromise. Some diving physicians feel that conditions inwhich there can be a waxing and waning of neurologicalsymptoms and signs, such as migraine or demyelinating
disease, contraindicate diving because an exacerbation or
attack of the preexisting disease (e.g.: a migraine with aura)
may be difficult to distinguishfrom neurological decompression sickness. A history of head
injury resulting in unconsciousness should be evaluated forrisk of seizure.

Relative Risk Conditions• Complicated Migraine Headaches whose symptoms or
severity impair motor or cognitive function, neurologic
manifestations• History of Head Injury with sequelae other than seizure• Herniated Nucleus Pulposus• Intracranial Tumor or Aneurysm• Peripheral Neuropathy• Multiple Sclerosis• Trigeminal Neuralgia• History of spinal cord or brain injury

Temporary Risk Condition
History of cerebral gas embolism without residual where
pulmonary air trapping has been excluded and for which
there is a satisfactory explanation and some reason tobelieve that the probability of recurrence is low.

Severe Risk Conditions
Any abnormalities where there is a significant probability of
unconsciousness, hence putting the diver at increased risk ofdrowning. Divers with spinal cord or brain abnormalities where
perfusion is impaired may be at increased risk ofdecompression sickness.
Some conditions are as follows:• History of seizures other than childhood febrile seizures• History of Transient Ischemic Attack (TIA) or Cerebrovascular Accident (CVA)• History of Serious (Central Nervous System, Cerebral or
Inner Ear) Decompression Sickness with residual
deficits

CARDIOVASCULAR SYSTEMS
Relative Risk Conditions
The diagnoses listed below potentially render the diver unable
to meet the exertional performance requirements likely to be
encountered in recreational diving. These conditions may leadthe diver to experience cardiac ischemia and its
consequences. Formalized stress testing is encouraged if
there is any doubt regarding physical performance capability.
The suggested minimum criteria for stress testing in suchcases is at least 13 METS.* Failure to meet the exercise
criteria would be of significant concern. Conditioning andretesting may make later qualification possible. Immersion inwater causes a redistribution of blood from the periphery into
the central compartment, an effect that is greatest in cold
water. The marked increase in cardiac preload during
immersion can precipitate pulmonary edema in patients with
impaired left ventricular function or significant valvulardisease. The effects of immersion can mostly be gauged byan assessment of the diver’s performance while swimming on
the surface. A large proportion of scuba diving deaths in North
America are due to coronary artery disease. Before being
approved to scuba dive, individuals older than 40 years arerecommended to undergo risk assessment for coronary arterydisease. Formal exercise testing may be needed to assess
the risk.
* METS is a term used to describe the metabolic cost. The
MET at rest is one, two METS is two times the resting level,
three METS is three times the resting level, and so on. The
resting energy cost (net oxygen requirement) is thus
standardized. (Exercise Physiology; Clark, Prentice Hall,
1975.)

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Relative Risk Conditions• History of Coronary Artery Bypass Grafting (CABG)• Percutaneous Balloon Angioplasty (PCTA) or Coronary
Artery Disease (CAD)• History of Myocardial Infarction• Congestive Heart Failure• Hypertension• History of dysrythmias requiring medication forsuppression• Valvular Regurgitation

Pacemakers
The pathologic process that necessitated should be
addressed regarding the diver’s fitness to dive. In thoseinstances where the problem necessitating pacing does
not preclude diving, will the diver be able to meet theperformance criteria?
* NOTE: Pacemakers must be certified by the
manufacturer as able to withstand the pressure changes
involved in recreational diving.

Severe Risks
Venousemboli,commonly
produced
duringdecompression, may cross major intracardiac right-to-leftshunts and enter the cerebral or spinal cord circulations
causing
neurologicaldecompression
illness.
Hypertrophic cardiomyopathy and valvular stenosis maylead to the sudden onset of unconsciousness during
exercise.

PULMONARY
Any process or lesion that impedes airflow from the lungs
placesthe diver at risk for pulmonary overinflation with alveolar
rupture and the possibility of cerebral air embolization. Manyinterstitialdiseasespredisposetospontaneous
pneumothorax: Asthma (reactive airway disease), Chronic
Obstructive Pulmonary Disease (COPD), cystic or cavitatinglung diseases may all cause air trapping. The 1996 Undersea
and Hyperbaric Medical Society (UHMS) consensus on diving
and asthma indicates that for the risk of pulmonary
barotrauma and decompression illness to be acceptably low,
the asthmatic diver should be asymptomatic and have normal
spirometry before and after an exercise test. Inhalation
challenge tests (e.g.: using histamine, hypertonic saline or
methacholine) are not sufficiently standardized to beinterpreted in the context of scuba diving.
A pneumothorax that occurs or reoccurs while diving may becatastrophic. As the diver ascends, air trapped in the cavity
expands and could produce a tension pneumothorax.
In addition to the risk of pulmonary barotrauma, respiratory
disease due to either structural disorders of the lung or chestwall or neuromuscular disease may impair exercise
performance. Structural disorders of the chest or abdominal
wall (e.g.: prune belly), or neuromuscular disorders, may
impair cough, which could be life threatening if water isaspirated. Respiratory limitation due to disease iscompounded by the combined effects of immersion (causing a
restrictive deficit) and the increase in gas density, which
increases in proportion to the ambient pressure (causing
increased airway resistance). Formal exercise testing may be
helpful.

Relative Risk Conditions• History of Asthma or Reactive Airway Disease (RAD)*• History of Exercise Induced Bronchospasm (EIB)*• History of solid, cystic or cavitating lesion*• Pneumothorax secondary to:-Thoracic Surgery-Trauma or Pleural Penetration*-Previous Over inflation Injury*• Obesity• History of Immersion Pulmonary Edema Restrictive
Disease*• Interstitial lung disease: May increase the risk of pneumothorax* Spirometry should be normal before and after exercise
Active Reactive Airway Disease, Active Asthma, Exercise
Induced Bronchospasm, Chronic Obstructive Pulmonary
Disease or history of same with abnormal PFTs or apositive exercise challenge are concerns for diving.

Severe Risk Conditions• History of spontaneous pneumothorax. Individuals who
have experienced spontaneous pneumothorax should avoid
diving, even after a surgical procedure designed to prevent
recurrence (such as pleurodesis). Surgical procedures either
do not correct the underlying lung abnormality(e.g.: pleurodesis,apical pleurectomy) or may not totallycorrect it (e.g.: resection of blebs or bullae).
• Impaired exercise performance due to respiratory
disease.

GASTROINTESTINAL
Temporary Risks
As with other organ systems and disease states, a process
which chronically debilitates the diver may impair exercise
performance. Additionally, dive activities may take place inareas remote from medical care. The possibility of acuterecurrences of disability or lethal symptoms must be
considered.

Temporary Risk Conditions• Peptic Ulcer Disease associated with pyloric obstruction
or severe reflux• Unrepaired hernias of the abdominal wall large enoughto contain bowel within the hernia sac could incarcerate.

Relative Risk Conditions• Inflammatory Bowel Disease• Functional Bowel Disorders

Severe Risks
Altered anatomical relationships secondary to surgery or
malformations that lead to gas trapping may cause serious
problems. Gas trapped in a hollow viscous expands as thedivers surfaces and can lead to rupture or, in the case of theupper GI tract, emesis. Emesis underwater may lead todrowning.
Severe Risk Conditions• Gastric outlet obstruction of a degree sufficient toproducerecurrent vomiting• Chronic or recurrent small bowel obstruction• Severe gastroesophageal reflux• Achalasia• Paraesophageal Hernia

ORTHOPAEDIC
Relative impairment of mobility, particularly in a boat or ashorewith equipment weighing up to 18 kgs/40 pounds must be
assessed. Orthopaedic conditions of a degree sufficient to
impair exercise performance may increase the risk.

Relative Risk Conditions• Amputation• Scoliosis must also assess impact on respiratory
function and exercise performance.
• Aseptic Necrosis possible risk of progression due toeffects of decompression (evaluate the underlying
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cause of decompression may accelerate/escalate theprogression).
• Back pain

personal fears• Claustrophobia and agoraphobia• Active psychosis• History of untreated panic disorder• Drug or alcohol abuse

HEMATOLOGICALOTOLARYNGOLOGICAL

Temporary Risk Conditions

Abnormalities resulting in altered rheological properties may
theoretically increase the risk of decompression sickness.
Bleeding disorders could worsen the effects of otic or sinus
barotrauma, and exacerbate the injury associated with inner
ear or spinal cord decompression sickness. Spontaneous
bleeding into the joints (e.g.: in hemophilia) may be difficult todistinguish from decompression illness.

Relative Risk Conditions• Sickle Cell Disease• Polycythemia Vera
• Leukemia• Hemophilia/Impaired Coagulation

METABOLIC AND ENDOCRINOLOGICAL
With the exception of diabetes mellitus, states of alteredhormonal or metabolic function should be assessed according
to their impact on the individual’s ability to tolerate themoderate exercise requirement and environmental stress ofsport diving. Obesity may predispose the individual todecompression sickness, can impair exercise tolerance and is
a risk factor for coronary artery disease.

Relative Risk Conditions• Hormonal Excess or Deficiency• Obesity• Renal Insufficiency

Severe Risk Conditions
The potentially rapid change in level of consciousness
associated with hypoglycemia in diabetics on insulin
therapy or certain oral hypoglycemic medications canresult in drowning. Diving is therefore generally
contraindicated, unless associated with a specialized
program that addresses these issues. [See “Guidelines for
Recreational Diving with Diabetes” at www/wrstc.com andwww.diversalertnetwork.org.]
Pregnancy: The effect of venous emboli formed duringdecompression on the fetus has not been thoroughly
investigated. Diving is therefore not recommended during
any stage of pregnancy or for women actively seeking tobecome pregnant.

BEHAVIORAL HEALTH
Behavioral: The diver’s mental capacity and emotional makeup are important to safe diving. The student diver must havesufficient learning abilities to grasp information presented tohim by his instructors, be able to safely plan and execute his
own dives and react to changes around him in the underwater
environment. The student’s motivation to learn and his ability
to deal with potentially dangerous situations are also crucial tosafe scuba diving.

Relative Risk Conditions• Developmental delay• History of drug or alcohol abuse• History of previous psychotic episodes• Use of psychotropic medications

Equalisation of pressure must take place during ascent anddescent between ambient water pressure and the external
auditory canal, middle ear and paranasal sinuses. Failure ofthis to occur results at least in pain and in the worst caserupture of the occluded space with disabling and possible
lethal consequences.
The inner ear is fluid filled and therefore noncompressible.
The flexible interfaces between the middle and inner ear, theround and oval windows are, however, subject to pressurechanges. Previously ruptured but healed round or oval window
membranes are at increased risk of rupture due to failure toequalise pressure or due to marked overpressurisation during
vigorous or explosive Valsalva manoeuvres.
The larynx and pharynx must be free of an obstruction to
airflow. The laryngeal and epiglotic structure must function
normally to prevent aspiration.
Mandibular and maxillary function must be capable of allowing
the patient to hold a scuba mouthpiece. Individuals who have
had mid-face fractures may be prone to barotrauma andrupture of the air filled cavities involved.

Relative Risk Conditions• Recurrent otitis externa• Significant obstruction of external auditory canal• History of significant cold injury to pinna• Eustachian tube dysfunction• Recurrent otitis media or sinusitis• History of TM perforation• History of tympanoplasty• History of mastoidectomy• Significant conductive or sensorineural hearing
impairment• Facial nerve paralysis not associated with barotrauma• Full prosthedontic devices• History of mid-face fracture• Unhealed oral surgery sites• History of head and/or neck therapeutic radiation• History of temperomandibular joint dysfunction• History of round window rupture

Severe Risk Conditions• Monomeric TM• Open TM perforation• Tube myringotomy• History of stapedectomy• History of ossicular chain surgery• History of inner ear surgery• Facial nerve paralysis secondary to barotrauma• Inner ear disease other than presbycusis• Uncorrected upper airway obstruction• Laryngectomy or status post partial laryngectomy• Tracheostomy• Uncorrected laryngocele• History of vestibular decompression sickness

Severe Risk Conditions• Inappropriate motivation to dive – solely to please
spouse,partner or family member, to prove oneself in theface of

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