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MEDICAL
STATEMENT
Participant
Record (Confidential Information)
www.padi.com
MEDICAL
HISTORY
To
the Participant:
The purpose of this medical
questionnaire is to find out if you should be examined by your doctor before
participating in recreational diver training. A positive response to a question
does not necessarily disqualify you from diving. A positive response means that
there is a preexisting condition that may affect your safety while diving and
you must seek the advice of your physician.
Please answer the following
questions on your past or present medical history with a YES or NO. If you are
not sure, answer YES. If any of these items apply to you, we must request that
you consult with a physician prior to participating in scuba diving. Your
instructor will supply you with a PADI Medical Statement and Guidelines for
Recreational Scuba Diver’s Physical Examination to take to your physician.
_____ Could
you be pregnant or are you attempting to become pregnant?
_____ Do you regularly take
prescription or nonprescription medications?
(with the
exception of birth control and anti- malarial)
_____ Are you over 45 years of
age and have one or more of the following?
currently smoke a pipe, cigars,
or cigarettes
have a high cholesterol level
have a family history of heart
attacks or strokes
Have
you ever had or do you currently have . . .
_____ Asthma,
or wheezing with breathing, or wheezing with exercise?
_____ Frequent
or severe attacks of hayfever or allergy?
_____ Frequent
colds, sinusitis or bronchitis?
_____ Any
form of lung disease?
_____ Pneumothorax
(collapsed lung)?
_____ History
of chest surgery?
_____
Claustrophobia or agoraphobia (fear of closed or open spaces)?
_____
Behavioral health problems?
_____ Epilepsy, seizures,
convulsions or take medications to prevent them?
_____ Recurring
migraine headaches or take medications to prevent them?
_____ History
of blackouts or fainting (full/partial loss of consciousness)?
_____ Do you frequently suffer
from motion sickness (seasick, carsick, etc.)?
_____ History
of diving accidents or decompression sickness?
_____ History
of recurrent back problems?
_____ History
of back surgery?
_____ History
of diabetes?
_____ History
of back, arm or leg problems following surgery, injury or fracture?
_____ Inability to perform
moderate exercise (example: walk one mile within 12 minutes)?
_____ History
of high blood pressure or take medicine to control blood pressure?
_____ History
of any heart disease?
_____ History of heart attacks?
_____ Angina or
heart surgery or blood vessel surgery?
_____ History
of ear or sinus surgery?
_____ History
of ear disease, hearing loss or problems with balance?
_____ History
of problems equalizing (popping) ears with airplane or mountain travel?
_____ History
of bleeding or other blood disorders?
_____ History
of any type of hernia?
_____ History
of ulcers or ulcer surgery?
_____ History
of colostomy?
_____ History
of drug or alcohol abuse?
Please
read carefully before signing.
This is a statement in which you
are informed of some potential risks
involved in scuba diving and of the
conduct required of you during the
scuba training program. Your signature
on this statement is required
for you to participate in the scuba
training program offered
by _________________________________________
and
Instructor
_______________________________________
located in the
Facility
city of __________________ and state
of ____________.
Read and discuss this statement
prior to signing it. You must
complete this Medical Statement, which
includes the medical-history
section, to enroll in the scuba-training
program. If you are
a minor, you must have this
Statement signed by a parent.
The
information I have provided about my medical history is accurate to the best of
my knowledge.
_______________________________________________________________________________________
__________________
Participant’s Signature Date
(day/month/year)
_______________________________________________________________________________________
__________________
Signatures of Parent or Guardian
(where applicable) Date (day/month/year)