Diver Medical Questionnaire
Complete this questionnaire as a prerequisite to recreational scuba diving or freediving activities.
Need a printable version?
Download the PDF to complete offline or bring on the day.
Participant Details
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.
Health Screening Questions
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.
2. I am over 45 years of age.
3. I struggle to perform moderate exercise (walk 1.6km in 14 minutes or swim 200m without resting), OR I have been unable to participate in normal physical activity due to fitness or health reasons within the past 12 months.
* Requires physician evaluation if Yes4. I have had problems with my eyes, ears, or nasal passages/sinuses.
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
* Requires physician evaluation if Yes6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.
8. I have had back problems, hernia, ulcers, or diabetes.
9. I have had stomach or intestine problems, including recent diarrhea.
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).
* Requires physician evaluation if YesParticipant Declaration & Signature
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 for my failure to disclose any existing or past health conditions.
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