Medical Questionnaire

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training.
A positive response to a question does not necessarily disqualify you from diving. A positiveresponse means that there is a preexisting condition that may affect your safetywhile diving and you must seek the advice of your physician prior to engaging indive activities.
Please answer the following questions on your past or present medical historywith a YES or NO.
If you are not sure, answer YES. If any of these items apply toyou, we must request that you consult with a physician prior to participating inscuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to yourphysician.

Participation date

If you will participate for several days, please put first date.

name

e-mail

----------------------------------------------------------------------------------------------------------------------------

I have had problems with my lungs, breathing, heart and/or blood affecting physical or mental performance.

Yes No

---- If your answer is Yes, please put multiple check mark-----

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung). Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise. A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. Symptoms affecting my lung, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.

----------------------------------------------------------------------------------------------------------------------------

I am over 45 years of age.

Yes No

---- If your answer is Yes, please put multiple check mark-----

I currently smoke or inhale nicotine by other means. I have high cholesterol level. I have high blood pressure. I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50(including abnormal heart rhythms, coronary artery disease of cardiomyopathy).

----------------------------------------------------------------------------------------------------------------------------

I struggle to perform moderate exercise (for example,walk 1.6 kilometer/one mile in 14 minutes or swim 200
meters/yards without resting),OR I have been unable to participate in a normal physical activity due to fitness or
health reasons within the past 12months.

Yes No

-----If your answer is Yes, please write a description.-----

----------------------------------------------------------------------------------------------------------------------------

I have had problems with my eyes, ears, or nasal passages/sinuses.

Yes No

---- If your answer is Yes, please put multiple check mark-----

Sinus surgery within the last 6 months. Ear disease or ear surgery, hearing loss, or problems with balance. Recurrent sinusitis within the past 12 months. Eye surgery within the past 3 months.

----------------------------------------------------------------------------------------------------------------------------

I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes No

-----If your answer is Yes, please write a description.-----

----------------------------------------------------------------------------------------------------------------------------

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from
persistent neurologic injury or disease.

Yes No

---- If your answer is Yes, please put multiple check mark-----

Head injury with loss of consciousness within the past 5 years. Persistent neurologic injury or disease. Recurring migraine headaches within the past 12 months, or take medications to prevent them. Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. Epilepsy, seizures, or convulsions, OR take medications to prevent them.

----------------------------------------------------------------------------------------------------------------------------

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 disability.

Yes No

---- If your answer is Yes, please put multiple check mark-----

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care. An addiction to drugs or alcohol requiring treatment within the last 5 years.

----------------------------------------------------------------------------------------------------------------------------

I have had back problems, hernia, ulcers, or diabetes.

Yes No

---- If your answer is Yes, please put multiple check mark-----

Recurrent back problems in the last 6 months that limit my everyday activity. Back or spinal surgery within the last 12 months. Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months. An uncorrected hernia that limits my physical abilities. Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

----------------------------------------------------------------------------------------------------------------------------

I have had stomach or intestine problems, including recent diarrhea.

Yes No

---- If your answer is Yes, please put multiple check mark-----

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. Dehydration requiring medical intervention within the last 7 days. Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). Active or uncontrolled ulcerative colitis or Crohn’s disease. Bariatric surgery within the last 12 months.

----------------------------------------------------------------------------------------------------------------------------

I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than
mefloquine/Lariam).

Yes No

-----If your answer is Yes, please write a description.-----

----------------------------------------------------------------------------------------------------------------------------

Your application will be completed when you click "SUBMIT" button in the confirmation page.