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medical form

    Questionnaire on the state of health for the practice of recreational diving

    Diving requires good physical and mental health. There are some medical conditions that can be dangerous during diving, and they are listed below. Those who have or are predisposed to any of these conditions should be evaluated by a doctor. This Diver's Medical Questionnaire provides a basis for determining if you should seek such an assessment. If you have any concerns about your fitness to dive and they are not represented on this form, please consult your physician before diving. References to "diving" in this form include both recreational scuba diving and breath-hold diving. This form is designed primarily as an initial medical exam for new divers, but is also appropriate for divers undergoing continuing education. For your safety and the safety of others who may dive with you, answer all questions honestly.

    INSTRUCTIONS

    Complete this questionnaire as a prerequisite for freediving or scuba diving training.
    Note to women: If you are pregnant, or trying to become pregnant, do not dive.
    Date of declaration of this form:
    Date of birth:

    Medical information

    1. I have had problems with my lungs or breathing, heart or blood YesDo not
      • Thoracic surgery, heart valve surgery, stent placement, or pneumothorax (collapsed lung). YesDo not
      • Asthma, wheezing, severe allergies, hay fever, or congested airways in the last 12 months that limits my physical activity or exercise. YesDo not
      • A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy, or stroke, or I am taking medication for any heart condition. YesDo not
      • Recurrent bronchitis and persistent cough in the last 12 months, or have been diagnosed with emphysema. YesDo not
    2. I am over 45 years old YesDo not
      • I currently smoke or inhale nicotine by other means. YesDo not
      • I have a high cholesterol level. YesDo not
      • I have high blood pressure. YesDo not
      • I have had a relative (first or second degree consanguinity) who died of sudden death or of heart disease or stroke before the age of 50 (including abnormal heart rhythms, coronary artery disease, or cardiomyopathy). YesDo not
    3. I find it difficult to engage in moderate exercise (for example, walking 1.6 kilometers in 12 minutes or swimming 200 meters without resting), or I have not been able to participate in normal physical activity due to fitness or health reasons in the past 12 months. YesDo not
    4. I have had problems with my eyes, ears, or nasal passages or sinuses YesDo not
      • Nasal surgery in the last 6 months. YesDo not
      • Ear diseases or ear surgery, hearing loss or balance disorders. YesDo not
      • Recurrent sinusitis in the last 12 months. YesDo not
      • Eye surgery in the last 3 months. YesDo not
    5. I have had surgery in the last 12 months, or have ongoing problems related to a previous surgery YesDo not
    6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or sustained neurological injury or disease YesDo not
      • Head injury with loss of consciousness in the last 5 years. YesDo not
      • Persistent neurological injury or disease. YesDo not
      • Recurring migraine headaches in the past 12 months or I take medication to prevent them. YesDo not
      • Blackouts or fainting (partial/full loss of consciousness) in the past 5 years. YesDo not
      • Epilepsy, fits or convulsions, or I take medicine to prevent them. YesDo not
    7. I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or drug or alcohol addiction YesDo not
      • Behavioral health, mental or psychological problems requiring medical or psychiatric treatment. YesDo not
      • Major depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. YesDo not
      • I have been diagnosed with a mental health condition or learning or developmental disorder that requires ongoing care. YesDo not
      • A drug or alcohol addiction that requires treatment within the past 5 years. YesDo not
    8. I have had back problems, hernia, ulcers or diabetes YesDo not
      • Recurring back problems in the last 6 months that limit my daily activity. YesDo not
      • Back or spine surgery in the last 2 months. YesDo not
      • Diabetes, either controlled by insulin or diet, or gestational diabetes in the last 12 months. YesDo not
      • An uncorrected hernia that limits my physical abilities. YesDo not
      • Active or untreated ulcers, problematic wounds or ulcer surgery in the last 6 months. YesDo not
    9. I have had stomach or intestinal problems, including recent diarrhea YesDo not
      • Ostomy surgery and I am not medically cleared to swim or engage in physical activity. YesDo not
      • Dehydration requiring medical intervention in the last 7 days. YesDo not
      • Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months. YesDo not
      • Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD). YesDo not
      • Active or uncontrolled ulcerative colitis or Crohn's disease. YesDo not
      • Bariatric surgery in the last 12 months. YesDo not
    10. I am taking prescription drugs (with the exception of birth control or antimalarial drugs) YesDo not
    I have honestly answered NO to the above 10 questions. I understand that a medical evaluation (?certificate?) is not required
    I have answered YES to one or more of the above questions. I accept and understand that I will need to bring a medical certificate before coming to dive with Buceo Cabo la Nao.
    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 from failure to disclose any existing or past health conditions.
    I have read and accept the Privacy and Cookie Policy.
    I am of age: YesDo not
    Electronic signature:
    Electronic Signature of Parent or Guardian:

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