Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

1. I have had problems with my lungs, breathing heart and/or blood affecting my normal psysical or mental performance.
YesNo

A1. Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g., stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
YesNo

A2. Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
YesNo

A3. A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
YesNo

A4. Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
YesNo

A5. Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.
YesNo

2. I am over 45 years of age.
YesNo

B1. I currently smoke or inhale nicotine by other means.
YesNo

B2. I have a high cholesterol level.
YesNo

B3. I have high blood pressure.
YesNo

B4. I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
YesNo

3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
YesNo

4. I have had problems with my eyes, ears, or nasal passages/sinuses.
YesNo

C1. Sinus surgery within the last 6 months.
YesNo

C2. Ear disease or ear surgery, hearing loss, or problems with balance.
YesNo

C3. Recurrent sinusitis within the past 12 months.
YesNo

C4. Eye surgery within the past 3 months.
YesNo

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
YesNo

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
YesNo

D1. Head injury with loss of consciousness within the past 5 years.
YesNo

D2. Persistent neurologic injury or disease.
YesNo

D3. Recurring migraine headaches within the past 12 months, or take medications to prevent them.
YesNo

D4. Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
YesNo

D5. Epilepsy, seizures, or convulsions, OR take medications to prevent them.
YesNo

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.
YesNo

E1. Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
YesNo

E2. Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
YesNo

E3. Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
YesNo

E4. An addiction to drugs or alcohol requiring treatment within the last 5 years.
YesNo

8. I have had back problems, hernia, ulcers, or diabetes.
YesNo

F1. Recurrent back problems in the last 6 months that limit my everyday activity.
YesNo

F2. Back or spinal surgery within the last 12 months.
YesNo

F3. Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
YesNo

F4. An uncorrected hernia that limits my physical abilities.
YesNo

F5. Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
YesNo

9. I have had back problems, hernia, ulcers, or diabetes.
YesNo

G1. Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
YesNo

G2. Dehydration requiring medical intervention within the last 7 days.
YesNo

G3. Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
YesNo

G4. Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
YesNo

G5. Active or uncontrolled ulcerative colitis or Crohn’s disease.
YesNo

G6. Bariatric surgery within the last 12 months.
YesNo

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
YesNo

Participant signature

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant
statement below by signing and dating it.

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

Furthermore, I agree to inform the dive center during the season if my health status changes and the answers to this questionnaire are modified as a result.

Participant's full name

Participant mail

Birthdate

Your dive club name

Participant Signature (or, if a minor, participant‘s parent/guardian signature required.)

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

Download the form here