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 that are not addressed 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 YesNo
      • Thoracic surgery, heart valve surgery, stent placement, or pneumothorax (collapsed lung). YesNo
      • Asthma, wheezing, severe allergies, hay fever, or congested airways in the last 12 months that limits my physical activity or exercise. YesNo
      • 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. YesNo
      • o Recurrent bronchitis and persistent cough in the last 12 months, or have been diagnosed with emphysema. YesNo
    2. I am over 45 years old YesNo
      • I currently smoke or inhale nicotine through other means. YesNo
      • I have a high cholesterol level. YesNo
      • I have high blood pressure. YesNo
      • o 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). YesNo
    3. I find it difficult to perform 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 last 12 months. YesNo
    4. I have had problems with my eyes, ears, or nasal passages or sinuses YesNo
      • Nasal surgery in the last 6 months. YesNo
      • Diseases of the ear or ear surgery, hearing loss or balance disorders. YesNo
      • Recurrent sinusitis in the last 12 months. YesNo
      • Eye surgery in the last 3 months. YesNo
    5. I have had surgery in the last 12 months, or have ongoing problems related to a previous surgery YesNo
    6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or sustained neurological injury or disease YesNo
      • Head injury with loss of consciousness in the last 5 years. YesNo
      • Persistent neurological injury or disease. YesNo
      • Recurring migraine headaches in the past 12 months or I take medication to prevent them. YesNo
      • Blackouts or blackouts (partial/full loss of consciousness) in the past 5 years. YesNo
      • Epilepsy, fits or convulsions, or I take medicine to prevent them. YesNo
    7. I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or drug or alcohol addiction YesNo
      • Behavioral health, mental or psychological problems requiring medical or psychiatric treatment. YesNo
      • Major depression, suicidality, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. YesNo
      • I have been diagnosed with a mental health condition or learning or developmental disorder that requires ongoing care. YesNo
      • A drug or alcohol addiction requiring treatment in the past 5 years. YesNo
    8. I have had back problems, hernia, ulcers or diabetes YesNo
      • Recurring back problems in the last 6 months that limit my daily activity. YesNo
      • Back or spine surgery in the last 2 months. YesNo
      • Diabetes, either controlled by insulin or diet, or gestational diabetes in the past 12 months. YesNo
      • An uncorrected hernia that limits my physical abilities. YesNo
      • Active or untreated ulcers, problematic wounds or ulcer surgery in the last 6 months. YesNo
    9. I have had stomach or intestinal problems, including recent diarrhea YesNo
      • Ostomy surgery and I am not medically cleared to swim or engage in physical activity. YesNo
      • Dehydration requiring medical intervention in the last 7 days. YesNo
      • Active or untreated stomach or intestinal ulcers or ulcer surgery in the past 6 months. YesNo
      • Frequent heartburn, regurgitation or gastroesophageal reflux disease. YesNo
      • Active or uncontrolled ulcerative colitis or Crohn's disease. YesNo
      • Bariatric surgery in the last 12 months. YesNo
    10. I am taking prescription drugs (with the exception of birth control or antimalarial drugs) YesNo
    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 Xaloc Dive Center.
    • 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 Cookies Policy.
    • I’m adult: YesNo
    Electronic signature:
    Electronic signature of the Parent or Guardian