DISCOVER SCUBA MEDICAL QUESTIONNAIRE

DISCOVER SCUBA MEDICAL QUESTIONNAIRE

First time, non certified divers, please answers these questions prior to booking dives. If YES is answered on any question, you will not be able to dive without a physician clearing you to dive for that particular question answered YES to.

1. Do you have a history of high blood pressure, angina, or take medication to control blood pressure?                                                       

2. Are you over 45 and have a family history of heart attack or stroke?          

3. Do you have a history of bleeding or blood disorder?                                     

4. Do you have a history of diabetes?   

5. Do you have a history of seizures, blackouts or fainting, convulsions, epilepsy, or take meds to control them?                                                          

6. Do you have a history of back, arm or leg problems following an injury, fracture, or surgery?                                

7. Do you have a history of fear of closed or open spaces, or panic attacks (claustrophobia, or agoraphobia)?                                           

8. Do you currently have an ear infection?                                                   

9. Do you have a history of ear disease, loss of hearing, or problems with balance?                                            

10. Do you have a history of ear or sinus surgery?                                           

11. Are you currently suffering from a cold, congestion, sinusitis, or bronchitis?                                                 

12. Do you have a history of respiratory problems, severe attacks from hayfever, allergies, or lung disease?                                                      

13. Have you had a collapsed lung(pneumothorax), or history of chest surgery?                                           

14. Do you have active asthma, or history of emphysema, or tuberculosis?                                             

15. Are you currently taking medication that carries a warning about any impairment of your mental or physical abilities?                  

16. Do you have behavioral health, mental or physiological problems, or a nervous system disorder?                   

17. Are you, or could you be pregnant?                                                   

18. Do you have a history of colostomy?                                                 

19. Do you have a history of heart disease, or heart attack, heart surgery or blood vessel surgery?