SDI Medical Release For Saguaro Scuba in Mesa, Arizona

Medical Statement

Participant Record. Confidential Information

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 positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.
Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?

Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)

Are you over 45 years of age and can answer YES to one or more of the following?
-currently smoke a pipe, cigar, or cigarettes? -have a high cholesterol level -have a family history of heart attack or stroke -are currently receiving medical care -have high blood pressure -diabetes mellitus. Even if controlled by diet alone.

Have you ever had or do you currently have...*

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.

Signature*

Date*

Signature of Parent or Guardian (where applicable)

Date

Medical Release

Step 1 of 2

Medical Statement

Participant Record. Confidential Information