Forms for diving courses SDI

Medical Statement - Participant Record

• Could you be pregnant, or are you attempting to become pregnant?*
  • Yes
  • No
• Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
  • Yes
  • No
• Are you over 45 years of age and can answer YES to one or more of the following:
• Currently smoke a pipe, cigars or cigarettes*
  • Yes
  • No
• have a high cholesterol level*
  • Yes
  • No
• have family history of haert attck or stroke*
  • Yes
  • No
• are currently receiving medical care*
  • Yes
  • No
• high blood pressure*
  • Yes
  • No
• diabetes mellitus, even if controlled by diet alone*
  • Yes
  • No
• have you ever had or do you currently have...:
• Asthma, or wheezing with breathing, or wheezing with exercise?*
  • Yes
  • No
• Frequent or severe attacks of hayfever or allergy?*
  • Yes
  • No
• Frequent colds, sinusitis or bronchitis?*
  • Yes
  • No
• Any form of lung disease?*
  • Yes
  • No
• Pneumothorax (collapsed lung)?*
  • Yes
  • No
• Other chest disease or chest surgery?*
  • Yes
  • No
• Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
  • Yes
  • No
• Epilepsy, seizures, convulsions or take medications to prevent them?*
  • Yes
  • No
• Recurring complicated migraine headaches or take medications to prevent them?*
  • Yes
  • No
• Blackouts or fainting (full/partial loss of consciousness)?*
  • Yes
  • No
• Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
  • Yes
  • No
• Dysentery or dehydration requiring medical intervention?*
  • Yes
  • No
• Any dive accidents or decompression sickness?*
  • Yes
  • No
• Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
  • Yes
  • No
• Head injury with loss of consciousness in the past five years?*
  • Yes
  • No
• Back or spinal surgery?*
  • Yes
  • No
• Diabetes?*
  • Yes
  • No
• Back, arm or leg problems following surgery, injury or fracture?*
  • Yes
  • No
• High blood pressure or take medicine to control blood pressure?*
  • Yes
  • No
• Heart disease?*
  • Yes
  • No
• Heart attack?*
  • Yes
  • No
• Angina, heart surgery or blood vessel surgery?*
  • Yes
  • No
• Sinus surgery?*
  • Yes
  • No
• Ear disease or surgery, hearing loss or problems with balance?*
  • Yes
  • No
• Recurrent ear problems?*
  • Yes
  • No
• Bleeding or other blood disorders?*
  • Yes
  • No
• Hernia?*
  • Yes
  • No
• Ulcers or ulcer surgery ?*
  • Yes
  • No
• A colostomy or ileostomy?*
  • Yes
  • No
• Recreational drug use or treatment for, or alcoholism in the past five years?*
  • Yes
  • No
• Do you wear glasses*
  • Yes
  • No
• Have you been diagnosed with Covid19 (Corona) in the past*
  • Yes
  • No