DIVING DRAFT Body

APPENDIX A University of Illinois at Urbana-Champaign Scientific Diving Program

Medical Approval Forms

To the Applicant:

You have requested approval for a scientific diving activity that makes considerable demands on your physical condition. Diving with certain defects amounts to asking for trouble, not only for you but for anyone who has to come to your aid if you get into difficulties in the water. For these reasons, the University insists that you have a doctor's approval on your fitness for diving.

You are asked to complete the Medical History Form mainly to save the doctor's time. Not all the questions have a direct bearing on your fitness for diving. Some have to do with medical problems which should be looked into whether they concern diving or not. All are questions the doctor would ask you if he had time.

To the Physician:

This person is an applicant for participation in scientific diving with self-contained underwater apparatus (SCUBA). This is an activity which puts unusual stress on the individual in several ways, and your opinion of his/her medical fitness is desired. The University of Illinois at Urbana-Champaign requires that all divers have a medical examination and physician approval once every twelve months.

Although a number of conditions can be considered definite contra-indications for diving, much depends on your clinical judgment. The applicant has been asked to complete the attached Medical History Form which may assist in calling possible significant conditions to your attention. Following the Medical History Form is a Medical Evaluation Form for your use, a Physician's Medical Approval Form to be completed and signed by you and returned to the University of Illinois at Urbana-Champaign's Diving Control Board, and an excerpt from the UIUC Scientific Diving Safety Manual describing the medical standards required.

Please complete and sign the Physician's Medical Approval Form after the physical examination. The form can either be given to the applicant to return to the Diving Control Board, or you may forward it directly to: Diving Control Board, Office of Vice Chancellor for Research, 601 East John Street, Champaign, Illinois 61820. Medical History Form

Address:

Telephone:

Age: Sex: Height Weight

Date of last physical examination: (month/year)

Date of last chest x-ray: (month/year)

Please answer the following questions, checking the appropriate box. If your answer to any of the questions requires an explanation, enter the number of the question and the explanation in the "Remarks" section of the form.

Yes No

1. ❑ ❑ Have you had previous experience in diving?

❑ ❑ Have you done any flying?

❑ ❑ If so, did you often have trouble equalizing pressure in your ears or sinuses?

❑ ❑ Can you go to the bottom of a swimming pool without having discomfort in your ears or sinuses?

2. ❑ ❑ Do you participate regularly in active sports? If so, specify what sport(s), and if not, indicate what exercise you normally obtain:

3. ❑ ❑ Have you ever been rejected for service or employment for medical reasons? If "yes" explain in remarks or discuss with the doctor.

4. ❑ ❑ Have you ever had an electrocardiogram?

❑ ❑ Have you ever had an electroencephalogram (brain wave study)? Please answer the following questions, checking the appropriate box. If your answer to any of the questions is "yes", enter the number of the question, the date(s) of occurrence, and any other pertinent information in the "Remarks" section of the form.

Yes No

1. ❑ ❑ Frequent colds or sore throat 2. ❑ ❑ Hay fever or sinus trouble 3. ❑ ❑ Trouble breathing through nose (other than during colds) 4. ❑ ❑ Painful or running ear, mastoid trouble, broken eardrum 5. ❑ ❑ Asthma or shortness of breath 6. ❑ ❑ Chest pain or persistent cough 7. ❑ ❑ Spells of fast, irregular, or pounding heartbeat 8. ❑ ❑ High or low blood pressure 9. ❑ ❑ Any kind of "heart trouble" 10. ❑ ❑ Frequent upset stomach, heartburn or indigestion, peptic ulcer 11. ❑ ❑ Frequent diarrhea or blood in stools 12. ❑ ❑ Belly or back ache lasting more than a day or two 13. ❑ ❑ Kidney or bladder disease: blood, sugar, or albumin in urine 14. ❑ ❑ Syphilis or gonorrhea 15. ❑ ❑ Broken bone, serious sprain or strain, dislocated joint 16. ❑ ❑ Rheumatism, arthritis, or other joint trouble 17. ❑ ❑ Severe or frequent headache 18. ❑ ❑ Head injury causing unconsciousness 19. ❑ ❑ Dizzy spells, fainting spells, or fits 20. ❑ ❑ Trouble sleeping, frequent nightmares, or sleepwalking 21. ❑ ❑ Nervous breakdown or periods of marked depression 22. ❑ ❑ Dislike for closed-in spaces, large open places, or high places 23. ❑ ❑ Any neurological condition 24. ❑ ❑ Train, sea, or air sickness 25. ❑ ❑ Alcoholism, or any drug or narcotic habit (including regular use of sleeping pills, Benzedrine, etc.) 26. ❑ ❑ Recent gain or loss of weight or appetite 27. ❑ ❑ Jaundice or hepatitis 28. ❑ ❑ Tuberculosis 29. ❑ ❑ Diabetes 30. ❑ ❑ Rheumatic fever 31. ❑ ❑ Any serious accident, injury or illness not mentioned above (describe under "Remarks") Remarks

Item # Date(s) Explanation

Certification

Please read the following statement and then sign and date the certification.

I, , certify that I have not withheld any information and that the above is accurate to the best of my knowledge.

Date: Signature:

Give this form to your physician prior to your physical examination. UIUC Scientific Diving Medical Evaluation Form

Name: Social Security No:

Date of Birth: Height: Weight:

Pulse: Blood Pressure:

Eyes: Near Vision Uncorrected: R L Corrected: R L Distant Vision Uncorrected: R L Corrected: R L Contact Lens ❑ Yes ❑ No Color Vision ❑ Normal ❑ Abnormal ❑ N.E.

Ears: Nose: Canals R L ❑ Normal Drums R L ❑ Spur Val Salva R L ❑ Deviated Septum

Mouth & Throat: Tonsils: ❑ Present ❑ Out ❑ Pathology Teeth: ❑ OK ❑ Orthodontia Neck: ❑ OK Thyroid: ❑ OK

Chest (Deformities): ❑ OKBreasts: ❑ OK Heart: ❑ OKLungs: ❑ OK Abdomen: ❑ OKHernia: ❑ OK Neuromuscular: ❑ OK Neuropsychiatric: ❑ OKEmotional Stability: ❑ OK

Tests: Audio Date: Chest X-ray Date: Urinalysis Date: Hematocrit Date: Other Date: Date: UIUC Scientific Diving Program Physician's Medical Approval Form

Applicant's Name:

Date of Medical Examination:

Medical Clearance is good for up to 12 months from the date of examination.

Medical Clearance granted until:

Comments:

Physician's Name (Print or Type)

Applicant's Signature Physician's Signature

Please submit this form to: Diving Control Board Institutional Review Board Office 528 E. Green Street, Ste. 203 Champaign, Illinois 61820 Excerpts from the UIUC Scientific Diving Safety Manual

Medical Standards

6.14 Content of Medical Examinations

Medical examinations conducted initially and annually shall consist of the following:

1. General medical history;

2. Diving-related medical history;

3. Basic physical examination;

4. The tests required by Table 1 (Section 6.15); and

5. Any additional tests the physician considers necessary such as EKG and/or stress test; Pulmonary function test.

6.15 Table 1.

Tests for Diving Medical Examination

Initial Examination (or within previous Annual Test 12 months) Reexamination Chest X-Ray X The extent of testing and Visual Acuity X examination to be Color Blindness X determined by examining Hearing Test X doctor Hematocrit or Hemoglobin X Urinalysis X Tetanus Vaccination X Every 10 years

6.16 Medical Examination Following Injury, Unconsciousness or Recompression Treatment

Medical examinations conducted after an injury or illness requiring hospitalization of more than 24 hours or after an episode of unconsciousness related to diving activity or after treatment in a recompression chamber following a diving accident shall be appropriate to the nature and extent of the injury or illness as determined by the examining physician.

6.17 Physician's Written Report

After any medical examination required by this standard, the UIUC Diving Control Board shall obtain a written report prepared by the examining physician which shall contain the examining physician's opinion of the individual's fitness to dive, including any recommended restrictions or limitations.

6.20 Contra-indications to Diving

The following conditions may be examples of either absolute or relative contra-indications to diving clearances; or at least may require special consultations and waivers, both medical and possibly legal.

1. Persons subject to spontaneous pneumothorax. 2. Persons subject to epileptic seizures or syncopal attacks.

3. Lung cysts or definite air-trapping lesions on chest X-ray.

4. Perforated ear drum.

5. Active asthma.

6. Drug addiction.

7. Diabetes where individual is subject to insulin shock or diabetic coma.

8. Ear surgery with placement of plastic strut in air-conduction chain.

9. Pregnancy.

10. History of myocardial infarction.

11. Decreased pulmonary reserve from any cause.

12. Malignancies (active) unless treated and without recurrence for 5 years.

13. Gross obesity in diving requiring decompression.

14. History of thoracotomy.

15. Impaired vision or blindness in one eye.

16. Chronic inability to equalize sinus and/or middle ear pressure.

17. Impaired organ function caused by alcohol or drug use.

18. Conditions requiring continuous medication for control (e.g., antihistamines, steroids, barbiturates, mood-altering drugs, or insulin).

19. Meniere's disease.

20. Hemoglobinopathies.

21. Cardiac abnormalities (e.g. , pathological heart block, valvular disease, intraventricular conduction defects other than isolated right bundle branch block, angina pectoris, arrhythmia, coronary artery disease).

22. Juxta-articular osteonecrosis.

23. Any lingering effects from the consumption of alcohol.

6.30 Visual Acuity

Applicants and divers should be able to read a watch and other appropriate gauges under diving conditions and be able to recognize familiar objects at a distance on the surface. Persons needing visual correction should have vision corrected, while diving, to the highest possible acuity.

6.40 Cardiovascular

Hemoglobin should be 95% or over and the hemogram should be in normal range. Diseases which might prevent active exercise should disqualify the applicant. Peripheral vascular disease which might interfere with gas exchange in an extremity should also disqualify the applicant. 6.50 Ear, Nose, and Throat

Applicants having acute or chronic sinus trouble should not dive unless free drainage of the sinuses is assured. Congestion secondary to upper respiratory infection (URI) or hay fever is a contra-indication to diving until free passage of air is possible. Applicants with acute or chronic ear trouble should not dive until the drum has normal appearance. Scarring from childhood otitis is not a contra-indication to diving. Healed perforations of the drum of at least two months duration should not be harmed by diving if special care is taken to keep the ears well-cleared during dives. Acute or chronic otitis externa should be considered harmful in diving until the canals are clear. Applicants with acute URI may be passed, but should be cautioned strictly against diving until the URI has completely cleared. Decongestants which work well on land have been known to fail in water, and severe squeeze can result. Bridgework or dentures should fit solidly.

6.60 Respiratory

Applicants with evidence of severe chronic lung disease, severe interference with free passage of air or with poor gas exchange should be rejected. A baseline chest X-ray should be taken or there should be evidence of a normal chest X-ray in the past 3 years. A history of asthma in childhood, with no attacks in the preceding three years, should not preclude the applicant's diving as long as there is verification by a physician that is no severe residual damage from the disease or ongoing problems.

6.70 Gastrointestinal

Applicants having chronic gastrointestinal disease, including ulcer or chronic ulcerated colitis, should not dive if any symptoms are present. History of bleeding ulcer is a contra-indication to a saturation diving situation where isolation is required for a week or more. If the process is quiescent, as judged by a physician, diving can be undertaken.

6.80 Endocrine

Endocrine disturbances which would interfere with normal oxygen-carrying capacities or response to stress should prevent the applicant from diving. Such entities would include severe hypothyroidism, Addison's disease, etc. Diabetics on medication should not participate in diving except under extremely carefully controlled conditions. The decision concerning approval for diving for a person with endocrine problems is a highly individualized one and should be based on the diving conditions to be encountered, depth, temperature ranges, and operational requirements.

6.90 Neuropsychiatric

This area is the most difficult to evaluate. If the response of the applicant to stress is questionable, seriously consider disqualification. Emergencies under water require cool judgment. It is estimated that the majority of diving deaths result from failure to react properly in emergency situations due to neuropsychiatric abnormalities.

Anyone on psycho chemotherapy should not dive under most situations; e.g. major tranquilizers-- thorazine, mellonil, would be a contra-indication, while occasional use of a mild sleeping medication such as benzodiazeprine might be acceptable. Again, the examiner's judgment is necessary.