Diver Medical

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Please read the statements on the right and respond with the truth. Make sure you read properly and check the boxes ONLY if correct. If you have to say yes to any of the questions please download the Full form and watch the video.

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If you need to reply YES to any of the statements on the right please watch the video bellow THEN DOWNLOAD AND FILL IN THE FULL FORM from the link below the video
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Quick Diver Medical

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    Full Name

    Instructors name

    Dive Centre

    Todays date

    Date of birth

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

    *I am over 45 years of age

    *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.

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

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

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

    *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 developmental disability.

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

    *I have had stomach or intestine problems, including recent diarrhea

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

    Please Sign here.