Dive Medical Questionnaire – Pro Dive Magnetic Island

Name *

Email *

Recreational scuba diving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below.

The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training.

For your safety, and that of others who may dive with you, answer all questions honestly, on your past or present medical history with a YES or NO. If you are not sure, answer YES.

This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education.

I have read and understood the above information

Could you be pregnant, or are you attempting to become pregnant? *

Yes

Are you over 45 years of age? *

Yes

I struggle to perform moderate exercise (for example, walk 1.6 kilometer in 14 minutes or swim 200 meters 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 *

Yes

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

Yes

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

Yes

Are currently receiving medical care? *

Yes

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

Yes

Asthma, wheezing, severe allergies, hay fever or congested airways within the past 12 months that limits my physical activity/exercise? *

Yes

I have/have had a problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR I am taking medication for any heart condition? *

Yes

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with Emphysema? *

Yes

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

Yes

I have high blood pressure or take medicine to control blood pressure? *

Yes

Sinus surgery within the last 6 months? *

Yes

I have/have had ear disease or ear surgery, hearing loss or problems with balance? *

Yes

Recurrent sinusitis within the last 12 months? *

Yes

Eye surgery within the last 3 months? *

Yes

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

Yes

I have/have had persistent neurologic injury or disease? *

Yes

Recurring migraine headaches within the past 12 months, or take medications to prevent them? *

Yes

Blackouts or fainting (full/partial loss of consciousness) within the last 5 years? *

Yes

I have/have had Epilepsy, seizures or convulsions, OR take medications to prevent them? *

Yes

I have/have had behavioral health, mental or psychological problems requiring medical/psychiatric treatment? *

Yes

I have/have had major depression, suicidal ideation, panic attacks or uncontrolled bipolar disorder, requiring medication/psychiatric treatment? *

Yes

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care? *

Yes

An addiction to drugs or alcohol requiring treatment within the last five years? *

Yes

Recurrent back problems in the last 6 months that limit my everyday activity? *

Yes

Back or spinal surgery within the last 12 months? *

Yes

I have/have had Diabetes, drug or diet controlled, OR gestational diabetes within the last 12 months? *

Yes

I have/have had an uncorrected hernia that limits my physical abilities? *

Yes

I have/have had ostomy surgery and do not have medical clearance to swim or engage in physical activity? *

Yes

Dehydration requiring medical intervention within 7 days of your diving activity? *

Yes

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months? *

Yes

I have/have had frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD)? *

Yes

I have/have had active or uncontrolled ulcerative colitis or Crohn's disease? *

Yes

I have/have had bariatric surgery within the last 12 months? *

Yes