Medical Certificate - TossaDivers

TossaDivers Medical Certificate

Before taking any diving course, it is necessary to fill out this medical questionnaire. Once filled out, we will validate the result and determine if a medical certificate is required to take the course.

Medical questionnaire

"*" indicates required fields

Name*

Surnames*

Date of birth*

Email*

Phone*

Form response date*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Are you of legal age?*

Yes

Legal guardian data*

First Last

Legal guardian signature*

What course are you going to take?*

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.

Signature*