SCUBA Medical Statement
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MEDICAL STATEMENT Participant Record (Confidential Information) Please read carefully before signing. This is a statement in which you are informed of some potential risks established safety procedures are not followed, however, there are involved in scuba diving and of the conduct required of you during the increased risks. scuba training program. Your signature on this statement is required for To scuba dive safely, you should not be extremely overweight or you to participate in the scuba training program offered out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air by STAFF and spaces must be normal and healthy. A person with coronary disease, a Instructor current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have GEORGIA TECH CAMPUS RECREATION CENTER located in the asthma, heart disease, other chronic medical conditions or you are tak- Facility ing medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis city of ATLANTA , state/province of GEORGIA . thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba Read this statement prior to signing it. You must complete this diving. Improper use of scuba equipment can result in serious injury. You Medical Statement, which includes the medical questionnaire section, to must be thoroughly instructed in its use under direct supervision of a enroll in the scuba training program. If you are a minor, you must have qualified instructor to use it safely. this Statement signed by a parent or guardian. If you have any additional questions regarding this Medical Diving is an exciting and demanding activity. When performed Statement or the Medical Questionnaire section, review them with your correctly, applying correct techniques, it is relatively safe. When instructor before signing. Divers Medical Questionnaire To the Participant: The purpose of this Medical Questionnaire is to find out if you should be exam- Please answer the following questions on your past or present medical history with ined by your doctor before participating in recreational diver training. A positive a YES or NO. If you are not sure, answer YES. If any of these items apply to response to a question does not necessarily disqualify you from diving. A you, we must request that you consult with a physician prior to positive response means that there is a preexisting condition that participating in scuba diving. Your instructor will supply you with an RSTC may affect your safety while diving and you must seek the advice of Medical Statement and Guidelines for Recreational Scuba Diver’s Physical your physician prior to engaging in dive activities. Examination to take to your physician. Could you be pregnant, or are you attempting to become pregnant? Dysentery or dehydration requiring medical intervention? Are you presently taking prescription medications? (with the exception of Any dive accidents or decompression sickness? birth control or anti-malarial) Inability to perform moderate exercise (example: walk 1.6 km/one mile Are you over 45 years of age and can answer YES to one or more of the within 12 mins.)? following? Head injury with loss of consciousness in the past five years? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level Recurrent back problems? • have a family history of heart attack or stroke Back or spinal surgery? • are currently receiving medical care • high blood pressure Diabetes? • diabetes mellitus, even if controlled by diet alone Back, arm or leg problems following surgery, injury or fracture? Have you ever had or do you currently have… High blood pressure or take medicine to control blood pressure? Asthma, or wheezing with breathing, or wheezing with exercise? Heart disease? Frequent or severe attacks of hay fever or allergy? Heart attack? Frequent colds, sinusitis or bronchitis? Angina, heart surgery or blood vessel surgery? Any form of lung disease? Sinus surgery? Pneumothorax (collapsed lung)? Ear disease or surgery, hearing loss or problems with balance? Other chest disease or chest surgery? Recurrent ear problems? Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)? Bleeding or other blood disorders? Epilepsy, seizures, convulsions or take medications to prevent them? Hernia? Recurring complicated migraine headaches or take medications to pre- Ulcers or ulcer surgery ? vent them? A colostomy or ileostomy? Blackouts or fainting (full/partial loss of consciousness)? Recreational drug use or treatment for, or alcoholism in the past five Frequent or severe suffering from motion sickness (seasick, carsick, years? etc.)? The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. Signature Date Signature of Parent or Guardian Date PRODUCT NO. 10063 (Rev. 06/07) Ver. 2.01 © PADI 1989, 1990, 1998, 2001, 2007 Page 1 of 6 © Recreational Scuba Training Council, Inc. 1989, 1990, 1998, 2001, 2007 STUDENT Please print legibly. Name Birth Date Age First Initial Last Day/Month/Year Mailing Address City State/Province/Region Country Zip/Postal Code Home Phone ( ) Business Phone ( ) Email FAX Name and address of your family physician Physician Clinic/Hospital Address Date of last physical examination Name of examiner Clinic/Hospital Address Phone ( ) Email Were you ever required to have a physical for diving? Yes No If so, when? PHYSICIAN This person applying for training or is presently certified to engage in scuba (self-contained underwater breathing apparatus) diving. Your opinion of the applicant’s medical fitness for scuba diving is requested. There are guidelines attached for your information and reference. Physician’s Impression I find no medical conditions that I consider incompatible with diving. I am unable to recommend this individual for diving. Remarks Date Physician’s Signature or Legal Representative of Medical Practitioner Day/Month/Year Physician Clinic/Hospital Address Phone ( ) Email Page 2 of 6 Guidelines for Recreational Scuba Diver’s Physical Examination Instructions to the Physician: Recreational SCUBA (Self-Contained Underwater Breathing from neurological decompression sickness. A history of head Apparatus) can provide recreational divers with an enjoyable injury resulting in unconsciousness should be evaluated for risk sport safer than many other activities. The risk of diving is of seizure. increased by certain physical conditions, which the relationship to diving may not be readily obvious. Thus, it is important to screen Relative Risk Conditions divers for such conditions. • Complicated Migraine Headaches whose symptoms or severity impair motor or cognitive function, neurologic The RECREATIONAL SCUBA DIVER’S PHYSICAL EXAMINA- manifestations TION focuses on conditions that may put a diver at increased risk • History of Head Injury with sequelae other than seizure for decompression sickness, pulmonary overinflation syndrome with subsequent arterial gas embolization and other conditions • Herniated Nucleus Pulposus such as loss of consciousness, which could lead to drowning. • Intracranial Tumor or Aneurysm Additionally, the diver must be able to withstand some degree of • Peripheral Neuropathy cold stress, the physiological effects of immersion and the optical effects of water and have sufficient physical and mental reserves • Multiple Sclerosis to deal with possible emergencies. • Trigeminal Neuralgia The history, review of systems and physical examination should • History of spinal cord or brain injury include as a minimum the points listed below. The list of condi- tions that might adversely affect the diver is not all-inclusive, but Temporary Risk Condition contains the most commonly encountered medical problems. The History of cerebral gas embolism without residual where pul- brief introductions should serve as an alert to the nature of the monary air trapping has been excluded and for which there risk posed by each medical problem. is a satisfactory explanation and some reason to believe that The potential diver and his or her physician must weigh the the probability of recurrence is low. pleasures to be had by diving against an increased risk of death Severe Risk Conditions or injury due to the individual’s medical condition. As with any Any abnormalities where there is a significant probability of recreational activity, there are no data for diving enabling the cal- unconsciousness, hence putting the diver at increased risk of culation of an accurate mathematical probability of injury. Experi- drowning. Divers with spinal cord or brain abnormalities where ence and physiological principles only permit a qualitative perfusion is impaired may be at increased risk of decompression assessment of relative risk. sickness. For the purposes of this document, Severe Risk implies that an Some conditions are as follows: individual is believed to be at substantially elevated risk of decom- pression sickness, pulmonary or otic barotrauma or altered con- • History of seizures other than childhood febrile seizures sciousness with subsequent drowning, compared with the gener- • History of Transient Ischemic Attack (TIA)