_________________________________ _______________ Name of Applicant (Print or Type) Date(Mo/Day/Year)To The PHYSICIAN:
This person is an applicant for training or is presently certified to engage in diving with self- contained underwater breathing apparatus (scuba). This is an activity which puts unusual stress on the individual in several ways. Your opinion on the applicant's medical fitness is requested. Scuba diving requires heavy exertion. The diver must be free of cardiovascular and respiratory disease. An absolute requirement is the ability of the lungs, middle ear and sinuses to equalize pressure. Any condition that risks the loss of consciousness should disqualify the applicant.
TESTS: Please initial that the following tests were completed.
[ ] Initial Examination [ ] Re-examination [ ] First over age 40 [ ] First over age 50 _____Medical History _____Medical History _____Chest X-Ray _____12 Lead EKG _____Pulmonary function _____Pulmonary function _____Audiogram _____Audiogram _____Visual acuity _____Visual acuity _____Complete blood count (CBC) _____Complete blood count (CBC) _____Blood chemistry _____Blood chemistry _____Urinalysis _____Urinalysis
[ ] APPROVAL. I find no medical condition(s) which I consider incompatible with diving.
[ ] RESTRICTED ACTIVITY APPROVAL. The applicant may dive in certain circumstances as described in REMARKS.
[ ] FURTHER TESTING REQUIRED. I have encountered a potential contraindication to diving. Additional medical tests must be performed before a final assessment can be made. See REMARKS.
[ ] REJECT. This applicant has medical condition(s) which, in my opinion, clearly would constitute unacceptable hazards to health and safety in diving
REMARKS:_______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________I have discussed the patient's medical condition(s) which would not seriously interfere with diving but which may seriously compromise subsequent health. The patient understands the nature of the hazards and the risks involved in diving with these defects.
Date & Signature: _____________________________________________________ M.D.
Print or Type Name: ___________________________________________________
Address: _____________________________________________________________
Telephone Number: ______________________________
My familiarity with applicant is: O With this exam only O Regular Physician for _____ years O Other (describe) _____________________________________________________ My familiarity with diving medicine: O Training in Hyperbaric Medicine. O Contact with the Divers Alert Network (919)684-2948 O Other (describe) _______________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Signature of Applicant ____________________________________________
DSM96