Padi Medical Questionnaire

Please answer the following questions on your past or present medical history

with a

or

. If you are not sure, answer

. 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 an RSTC 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?

_____ Are you presently taking prescription medications? (with the exception of

birth control or anti-malarial)

_____ 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

• have a high cholesterol level

• have a family history of heart attack or stroke

• are currently receiving medical care

• high blood pressure

• diabetes mellitus, even if controlled by diet alone

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)?

_____ Other chest disease or chest surgery?

_____ Behavioral health, mental or psychological problems (Panic attack, fear of

closed or open spaces)?

_____ Epilepsy, seizures, convulsions or take medications to prevent them?

_____ Recurring complicated migraine headaches or take medications to prevent

them?

_____ Blackouts or fainting (full/partial loss of consciousness)?

_____ Frequent or severe suffering from motion sickness (seasick, carsick,

etc.)?

_____ Dysentery or dehydration requiring medical intervention?

_____ Any dive accidents or decompression sickness?

_____ Inability to perform moderate exercise (example: walk 1.6 km/one mile

within 12 mins.)?

_____ Head injury with loss of consciousness in the past five years?

_____ Recurrent back problems?

_____ Back or spinal surgery?

_____ Diabetes?

_____ Back, arm or leg problems following surgery, injury or fracture?

_____ High blood pressure or take medicine to control blood pressure?

_____ Heart disease?

_____ Heart attack?

_____ Angina, heart surgery or blood vessel surgery?

_____ Sinus surgery?

_____ Ear disease or surgery, hearing loss or problems with balance?

_____ Recurrent ear problems?

_____ Bleeding or other blood disorders?

_____ Hernia?

_____ Ulcers or ulcer surgery ?

_____ A colostomy or ileostomy?

_____ Recreational drug use or treatment for, or alcoholism in the past five

years?

Divers Medical Questionnaire

I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.