MEDICAL STATEMENT
 

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Participant Record (confidential information)
Please read carefully before signing
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 ___________________________ and
                           Instructor
__________________________Located
                           Facility
in the city of ______________________

and state/province of _______________

Read this statement prior to signing it. You must complete this medical statement, which includes the medical questionnaire section, to enrol in the scuba training program. If you are a minor, you must have this statement signed by a parent or guardian. Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, its relatively safe. When established safety procedures are not followed, there are increased risks. To scuba dive safely, you must not be extremely overweighed or out of condition. Diving can be strenuous under certain conditions. A person with a coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of drugs or alcohol should not dive.

Your respiratory system and circulation systems must be in good health. All body airspaces must normal ad healthy. If you have asthma, heart disease or other chronic medial 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 equalizing while scuba diving. Improper

use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct 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 answer the following questions on your past or present medical history with a YES or a NO. If you are not sure, answer YES. If any of these items apply to you, we must request that your consult with a physician prior to participating in scuba diving. Your instructor will supply with a RSTC Medical statement and guidelines for recreational Scuba Divers Physician examination to take to your physician.

Name ______________________________________________________________

Address ____________________________________________________________

City _________________________ Postal code ____________________________

Country _________________________ Phone ______________________________

E-mail_____________________________________ Birth date_________________
 
YES/NO
1 Could you be pregnant or are you attempting to become pregnant
__________
2 Do you regularly take prescription of non-prescription medications (With the exception of birth control)
__________
3 Are you over 45 years of age and can answer YES to one or more of the following:
__________
  • Currently smoke a pipe, cigars or and cigarettes
  • Have a high cholesterol level
  • Have a family history of hearth 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…..
4 Asthma or wheezing with breathing, or wheezing with exercise?
__________
5 Frequent or severe attacks of hay fever or allergy
__________
6 Frequently cold, sinusitis or bronchitis?
__________
7 Any form of lung disease?
__________
8 Pneumothorax (collapsed lung)
__________
9 Other chest disease or chest surgery?
__________
10 Behaviour health, mental or psychological problems (panic attack, fear for closed or open spaces)?
__________
11 Epilepsy, seizures, convulsions or take medications to prevent them?
__________
12 Blackouts or fainting (full/partial loss of consciousness)?
__________
13 Frequent or sever suffering from motion sickness (seasick, carsick etc.)?
__________
14 Dysentery or dehydration requiring medical intervention?
__________
15 Any dive accidents or decompression sickness?
__________
16 History or recurrent back problems?
__________
17 Inability to perform moderate exercise (example: walk 1.6 km/1 mile within 12 minutes)?
__________
18 Head injury with loss of consciousness in the past five years?
__________
19 Recurrent back problems?
__________
20 Back or spinal injury?
__________
21 Diabetes?
__________
22 Back, arm or leg problems following surgery, injury or fracture?
__________
23 High blood pressure or take medicine to control high blood pressure?
__________
23 High blood pressure or take medicine to control high blood pressure?
__________
24 Heart disease?
__________
25 Angina, heart surgery or blood vessel surgery?
__________
26 Sinus surgery?
__________
27 Era disease or surgery, hearing loss or problems with balance?
__________
28 Recurrent ear problems?
__________
29 Bleeding or other blood disorders?
__________
30 Hernia?
__________
31 Ulcers or ulcer surgery?
__________
32 Colostomy or ileostomy?
__________
33 Recreational drugs for use or treatment for, alcoholism in the past five years?
__________
 
The information I have provided about my medical history is accurate to the best of my knowledge. I exempt my Instructors, facility, which I received my instruction from all liability or responsibility whatsoever for personal injury, property damage or wrongful death however caused by my negligence.
 

_______________________

DOCTORS SIGNATURE

_______________________

PARTICIPANT SIGNATURE

_______________________

DATE

____________________________

NAME IN CAPITAL OF APPLICANT

___________________________

PARENT/GUARDIAN SIGNATURE