Dive Medical Questionnaire - Pro Dive Magnetic Island

Divers Medical Questionnaire

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in scuba diving activities. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety or the safety of others while diving and you must seek the advice of your physician prior to engaging in dive activities.

Name Email

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

Yes

Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)

Yes

Are you over 45 years of age?

Yes

Do you have a BMI over 30 and a waist circumference greater than 102cm for males and 88cm for Females?

Yes

Are currently receiving medical care?

Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?

Yes

Any form of lung disease?

Yes

Pneumothorax (collapsed lung)?

Yes

Other chest disease or chest surgery?

Yes

Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?

Yes

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

Yes

Recurring complicated migraine headaches or take medications to prevent them?

Yes

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

Yes

Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?

Yes

Dysentery or dehydration requiring medical intervention?

Yes

Any dive accidents or decompression sickness?

Yes

Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins)?

Yes

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

Yes

Recurrent back problems?

Yes

Back or spinal surgery?

Yes

Diabetes?

Yes

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

Yes

High blood pressure or take medicine to control blood pressure?

Yes

Heart disease?

Yes

Heart attack?

Yes

Angina, heart surgery or blood vessel surgery?

Yes

Sinus surgery?

Yes

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

Yes

Recurrent ear problems?

Yes

Bleeding or other blood disorders?

Yes

Hernia?

Yes

Ulcers or ulcer surgery?

Yes

A colostomy or ileostomy?

Yes

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

Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.