TossaDivers Documents

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Name*

Surnames*

Email*

Phone*

Are you of legal age?*

Yes

Form response date*

DD dash MM dash YYYY

Legal guardian data*

First Last

Legal guardian signature*

Medical questionnaire

1 - I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.(If you answer YES, answer questions A)*

Yes

2 - I am over 45 years of age.(If you answer YES, answer questions B)*

Yes

3 - 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 12 months.*

Yes

4 - I have had problems with my eyes, ears, or nasal passages/sinuses. (If you answer YES, answer questions C)*

Yes

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

Yes

6 - I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease(If you answer YES, answer questions D)*

Yes

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.(If you answer YES, answer questions E)*

Yes

8 - I have had back problems, hernia, ulcers, or diabetes (If you answer YES, answer questions F)*

Yes

9 - I have had stomach or intestine problems, including recent diarrhea (If you answer YES, answer questions G)*

Yes

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

Yes

Section A

A1 - Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease*

Yes

A2 — Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise*

Yes

A3 — 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.*

Yes

A4 — Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*

Yes

A5— Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*

Yes

Section B

B1 - I am over 45 years old and currently smoke or inhale nicotine through other means.*

Yes

B2 - I am over 45 years old and have high cholesterol.*

Yes

B3 - I am over 45 years old and have high blood pressure.*

Yes

B4 - I am over 45 years old and have had a family member (1st or 2nd degree of consanguinity) who died of sudden death, heart disease or stroke before the age of 50, or I have a family history of heart disease before the age of 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*

Yes

Section C

C1 - I have/had: Sinus surgery in the last 6 months.*

Yes

C2 - I have/had: Ear disease or ear surgery, hearing loss or balance disorders.*

Yes

C3 - I have/had: Recurrent sinusitis in the last 12 months.*

Yes

C4 - I have/had: Eye surgery in the last 3 months.*

Yes

Section D

D1 - I have/had: Head injury with loss of consciousness in the last 5 years.*

Yes

D2 - I have/had: Persistent neurological injuries or illnesses.*

Yes

D3 - I have/had: Recurrent migraine headaches in the last 12 months, or take medication to prevent them.*

Yes

D4 - I have/had: Fainting spells or loss of consciousness (partial or total) in the last 5 years.*

Yes

D5 - I have/had: Epilepsy, seizures or convulsions, or take medication to prevent them.*

Yes

Section E

E1 - I have/had: Behavioral health, mental or psychological problems that require medical or psychiatric treatment.*

Yes

E2 - I have/had: Major depression, suicidal tendencies, panic attacks, uncontrolled bipolar disorder that requires medication/psychiatric treatment.*

Yes

E3 - I have/had: Been diagnosed with a mental health condition or a learning or developmental disorder that requires ongoing attention.*

Yes

E4 - I have/had: An addiction to drugs or alcohol that requires treatment in the last 5 years.*

Yes

Section F

F1 - I have/had: Recurrent back problems in the last 6 months that limit my daily activity.*

Yes

F2 - I have/had: Back or spinal surgery in the last 12 months.*

Yes

F3 - I have/had: Diabetes, either controlled by insulin or diet, or gestational diabetes in the last 12 months.*

Yes

F4 - I have/had: An uncorrected hernia that limits my physical abilities.*

Yes

F5 - I have/had: Active or untreated ulcers, problem wounds, or ulcer surgery in the last 6 months.*

Yes

Section G

G1 - I have: Ostomy surgery and do not have medical authorization to swim or engage in physical activity.*

Yes

G2 - I have: Dehydration that requires medical intervention in the last 7 days.*

Yes

G3 - I have: Active or untreated stomach or intestinal ulcers, or ulcer surgery in the last 6 months.*

Yes

G4 - I have: Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).*

Yes

G5 - I have: Active or uncontrolled ulcerative colitis or Crohn's disease.*

Yes

G6 - I have: Bariatric surgery in the last 12 months.*

Yes

Acceptance of the declaration.

If you answered YES to questions 3, 5, or 10 above, or to any of the questions on the questionnaire, download, read, and accept the statement with the date and your signature, and take the Medical Evaluation Form to your physician for a medical evaluation. Participation in a scuba training program requires evaluation and approval from your physician.*

I acknowledge that I have answered all questions truthfully. If you answered YES to any of the above questions, download the Medical Questionnaire and take it to your physician to authorize you for underwater activities.

Participant Statement: I have answered all questions honestly and understand that I accept responsibility for any consequences resulting from any question I may have answered inaccurately or for not disclosing any existing or past health condition.*

I have read and accept the participant statement.

Signature*

Diving Certification*

Open Water

Advanced

Rescue

Divemaster

Instructor

Other

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