Barra Dive - Medical Statement

MEDICAL STATEMENT
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Participant Record (Confidential Information) This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program:

Offered by: ..............................................................................................................................................

Instructor: ................................................................................................................................................

Located in the Facility city of: ...................................................................................................................

State/province of: .....................................................................................................................................

Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian.
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Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks.

To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.

If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing.

Please read carefully before signing. The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice
of your physician prior to engaging in dive activities.

DIVERS MEDICAL QUESTIONNAIRE

To the Participant: Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. 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.

YES	NO	Could you be pregnant, or are you attempting to become pregnant?
YES	NO	Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)
YES	NO	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:

YES	NO	Asthma, or wheezing with breathing, or wheezing with exercise?
YES	NO	Frequent or severe attacks of hayfever or allergy?
YES	NO	Frequent colds, sinusitis or bronchitis?
YES	NO	Any form of lung disease?
YES	NO	Pneumothorax (collapsed lung)?
YES	NO	Other chest disease or chest surgery?
YES	NO	Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
YES	NO	Epilepsy, seizures, convulsions or take medications to prevent them?
YES	NO	Recurring complicated migraine headaches or take medications to prevent them?
YES	NO	Blackouts or fainting (full/partial loss of consciousness)?
YES	NO	Frequent or severe suffering from motion sicknes (seasick, carsick, etc.)?
YES	NO	Dysentery or dehydration requiring medical intervention?
YES	NO	Any dive accidents or decompression sickness?
YES	NO	Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
YES	NO	Head injury with loss of consciousness in the past five years?
YES	NO	Recurrent back problems?
YES	NO	Back or spinal surgery?
YES	NO	Diabetes?
YES	NO	Back, arm or leg problems following surgery, injury or fracture?
YES	NO	High blood pressure or take medicine to control blood pressure?
YES	NO	Heart disease?
YES	NO	Heart attack?
YES	NO	Angina, heart surgery or blood vessel surgery?
YES	NO	Sinus surgery?
YES	NO	Ear disease or surgery, hearing loss or problems with balance?
YES	NO	Recurrent ear problems?

Barra Dive - Medical Statement

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