Medical Questionnaire - Stollis Divebase

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Medical Questionnaire

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Medical Questionnaire
 

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Diver Medical | Participant Questionnaire

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 ftness 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, blood, or have been diagnosed with COVID-19.*

 
2.
I am over 45 years of age.*

 
3.
I struggle to perform moderate exercise e (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 ftness or health reasons within the past 12 months. *

if YES (!):
Participation in diving activities requires your physician’s approval.
 
4.
I have had problems with my eyes, ears, or nasal passages/sinuses.*

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

if YES (!):
Participation in diving activities requires your physician’s approval.
 
6.
I have lost consciousness, had migraine headaches, seizures, stroke, signifcant head injury, or suffer from persistent neurologic injury or disease.*

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

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

 
9.
I have had stomach or intestine problems, including recent diarrhea.*

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

if YES (!):
Participation in diving activities requires your physician’s approval.
 
Participant Statement
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.

(!) If you answered YES to questions 3, 5 or 10 OR to any of the questions in the Boxes, please DO NOT SUBMIT this form (for reasons of privacy / data protection).
In this case you need a medical evaluation. Participation in diving activities requires your physician’s approval..
This questionnaire along with the Physician`s Evaluation Form is available for download HERE herunterladen.

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.
 
Gender*
First Name*
Last Name*

Participant Signature (or, if a minor, participant‘s parent/guardian signature required.)
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Subsequently ...
• you will receive a confirmation email with your details
• you will be redirected to the page with the upload link and further forms.

If the confirmation email does not arrive, please check your spam folder.

Fields with asterisk (*) required.
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