HEALTH DECLARATION FORM / COVID-19
Read this statement prior to signing it. You must complete this additional medical questionnaire to enrol in a diver training program or toparticipate in any diving activity. If you are a minor, you must have this statement signed by your parent or guardian.

DIVER MEDICAL QUESTIONNAIRE
The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Please answer the following questions with a YES orNO. If you are not sure, answer YES. A positive response means that there may be a preexisting condition that could affect your safety while
diving. If any of these items apply to you, we must request that you consult with a physician, preferably a specialist in diving medicine, prior toparticipating in diving activities.
Within the 40 days immediately preceding the date of this Health Declaration Form, have you:
1.

TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR– SARS-COV2) OR BEEN
IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?

YES
2.

NO

EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN;
DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?

YES
3.

NO

BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW
CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?

YES
4.

NO

BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEWCORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?

YESNO

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for anyomissions in disclosing my existing or past health conditions.
I also commit to inform instructor / dive centre nameabout any symptom that may arrive after having filled in thisdeclaration and/or having come into contact with someone who has tested positive after signing the declaration.

Full Name

Date

Guardian’s Full Name

Signature

Date

Signature

ADDITIONAL DECLARATIONS / COVID-19
I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged byinstructor / dive centre nameinstructor / dive centre name

I WILL accept and observe all instructions by, and will take all reasonable preventive steps that may be recommended by, or any relevant public authority.
instructor / dive centre nameintended to abide by all existing

regulations, required to help prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities.
I ACKNOWLEDGE and ACCEPT that this declaration will be considered as my consent to instructor
dive centre nameo retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring

the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.
Full Name

Signature

Date

Guardian’s Full Name

Signature

Date

PLEASE NOTECOVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalesce before returning to full activities – aprocess that can take weeks or months depending on symptom severity (1).
MEDICAL RECOMMENDATIONS (2):•Divers who have had symptomatic COVID-19, should wait a minimum of TWO months, preferable THREE, before resuming their diving activities.

•

Divers who have tested positive with COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.

•

Divers who have been hospitalised with pulmonary symptoms related to COVID-19, should, after a three-month waiting period, undergo completepulmonary function testing as well as a cardiac evaluation with echocardiography and exercise test (exercise electrocardiography) to ascertain
normal cardiac function prior to their return to diving.

GENERAL RECOMMENDATION•Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES(1)

Return to Diving Post COVID-19 - issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.

(2)

Diving after COVID-19 pulmonary infection. A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG).

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students,
before taking up any diving activity with them.
The Form has been developed by the DAN Europe Medical Division team, based on information available as of May 2020. The epidemiological situationis constantly evolving.As a result, this document may be subject to changes and updates.

With the support of