Certified Diver Medical Questionnaire

Name

First

Last

IMPORTANT: PLEASE READ

Since completing your last dive medical have you suffered any illness, injury or surgery that may effect your ability to dive safely?

Yes

Please List:

Are you currently suffering any illness or injury?

Yes

Please List:

Are you currently taking any prescription medication other than the contraceptive pill?

Yes

Please List:

Is there any other condition, fact or circumstance that may affect your fitness or ability to dive safely?

Yes

Please List:

ACKNOWLEDGEMENT: Please read carefully

I have read, understood and agree to the above points