DIVING MEDICAL HISTORY FORM

(To Be Completed By Applicant-Diver)

Name ______________________________________ Sex ____ Age ___ Wt.___ Ht. ___

Sponsor ____________________________________________	Date ___/___/___
	(Dept./Project/Program/School, etc.)		(Mo/Day/Yr)
TO THE APPLICANT:

Scuba diving makes considerable demands on your physical and emotional condition. Diving with particular defects amounts to asking for trouble not only for yourself, but to anyone coming to your aid if you get into difficulty in the water. Therefore, it is prudent to meet certain medical and physical requirements before beginning a diving or training program.

Your answers to the questions are more important, in many instances, in determining your fitness than what the physician may see, hear or feel when you are examined. Obviously, you should give accurate information or the medical screening procedure becomes useless.

This form shall be kept confidential. If you believe any question amounts to invasion of your privacy, you may elect to omit an answer, provided that you shall subsequently discuss that matter with your own physician and he/she must then indicate, in writing, that you have done so and that no health hazard exists.

Should your answers indicate a condition which might make diving hazardous, you will be asked to review the matter with your physician. In such instances, his/her written authorization will be required in order for further consideration to be given to your application. If your physician concludes that diving would involve undue risk for you, remember that he/she is concerned only with your well-being and safety. Respect the advice and the intent of this medical history form.

    Please indicate whether or not the following apply to you:
  1. Yes No : Convulsions, seizures, or epilepsy
  2. Yes No : Fainting spells or dizziness
  3. Yes No : Been addicted to drugs
  4. Yes No : Diabetes
  5. Yes No : Motion sickness or sea/air sickness
  6. Yes No : Claustrophobia
  7. Yes No : Mental disorder or nervous breakdown
  8. Yes No : Are you pregnant?
  9. Yes No : Do you suffer from menstrual problems?
  10. Yes No : Anxiety spells or hyperventilation
  11. Yes No : Frequent sour stomachs, nervous stomachs or vomiting spells
  12. Yes No : Had a major operation
  13. Yes No : Presently being treated by a physician
  14. Yes No : Taking any medication regularly (even nonprescription)
  15. Yes No : Been rejected or restricted from sports
  16. Yes No : Headaches (frequent and severe)
  17. Yes No : Wear dental plates
  18. Yes No : Wear glasses or contact lenses
  19. Yes No : Bleeding disorders
  20. Yes No : Alcoholism
  21. Yes No : Any Problems related to diving
  22. Yes No : Nervous tension or emotional problems
  23. Yes No : Take tranquilizers
  24. Yes No : Perforated ear drums
  25. Yes No : Hay fever
  26. Yes No : Frequent sinus trouble, frequent drainage from the nose, post-nasal drip, or stuffy nose
  27. Yes No : Frequent earaches
  28. Yes No : Drainage from the ears
  29. Yes No : Difficulty with your ears in airplanes or on mountains
  30. Yes No : Ear surgery
  31. Yes No : Ringing in your ears
  32. Yes No : Frequent dizzy spells
  33. Yes No : Hearing problems
  34. Yes No : Trouble equalizing pressure in your ears
  35. Yes No : Asthma
  36. Yes No : Wheezing attacks
  37. Yes No : Cough (chronic or recurrent)
  38. Yes No : Frequently raise sputum
  39. Yes No : Pleurisy
  40. Yes No : Collapsed lung (pneumothorax)
  41. Yes No : Lung cysts
  42. Yes No : Pneumonia
  43. Yes No : Tuberculosis
  44. Yes No : Shortness of breath
  45. Yes No : Lung problem or abnormality
  46. Yes No : Spit blood
  47. Yes No : Breathing difficulty after eating particular foods, after exposure to particular pollens or animals
  48. Yes No : Are you subject to bronchitis
  49. Yes No : Subcutaneous emphysema (air under the skin)
  50. Yes No : Air embolism after diving
  51. Yes No : Decompression sickness
  52. Yes No : Rheumatic fever
  53. Yes No : Scarlet fever
  54. Yes No : Heart murmur
  55. Yes No : Large heart
  56. Yes No : High blood pressure
  57. Yes No : Angina (heart pains or pressure in the chest)
  58. Yes No : Heart attack
  59. Yes No : Low blood pressure
  60. Yes No : Recurrent or persistent swelling of the legs
  61. Yes No : Pounding, rapid heartbeat or palpitations
  62. Yes No : Easily fatigued or short of breath
  63. Yes No : Abnormal EKG
  64. Yes No : Joint problems, dislocations or arthritis
  65. Yes No : Back trouble or back injuries
  66. Yes No : Ruptured or slipped disk
  67. Yes No : Limiting physical handicaps
  68. Yes No : Muscle cramps
  69. Yes No : Varicose veins
  70. Yes No : Amputations
  71. Yes No : Head injury causing unconsciousness
  72. Yes No : Paralysis
  73. Yes No : Have you ever had an adverse reaction to medication?
  74. Yes No : Do you smoke?
  75. Yes No : Have you ever had any other medical problems not listed? If so, please list or describe below: 
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Comments: ________________________________________________________________
__________________________________________________________________________
I certify that the above answers and information represent an accurate and complete description of my medical history.

Signature _____________________________ Date _____________________


DSM96

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