×
Home
About
Lessons
SDI Lessons
Forms and Registration
All ELearning Lessons
Scuba Certification Map
Learn To Dive For $99
Discover Scuba
SDI Refresher
Advanced Diver
SDI Rescue Diver Certification
SDI Divemaster Certification
Assistant Instructor
Instructor Certification
Specialties
PADI Lessons
Forms and Registration
All PADI ELearning Certifications
PADI Scuba Certification Map
Learn To Scuba Dive With PADI
Discover Scuba
PADI Refresher
Advanced Open Water
Rescue Diver
PADI Divemaster
Specialties
Disabled Diving
Disabled Diver Program
Disabled Diving
Disabled Diver Dive Buddy Program
Disabled Diver Instructor Program
Professional
ERDI Public Safety
ERD I
ERD II
SDI Visual Inspection Procedures
Visual Inspection Course
Visual Inspection Instructor Course
Eddy Current and Advanced Thread Inspection
Shop
SALE ITEMS
Packages
Rental Sales
Used Gear
Equipment
Masks
Prescription Dive Masks
Snorkels
Fins
Buoyancy Compensators
Regulators
Computers
Gauges
Snorkel Gear
Add On Gear
Cases & Bags
Knives
Photography
Lights
Scooters And ROVs
Accessories
Equipment Care
Flags & Floats
Retractors & Clips
Signaling Devices
Exposure Gear
Boots
Gloves
Hoods
Wet Suits
Dry Suits
Undergarments
Rash Guards
Training
PADI Materials
PADI Courses
SDI Materials
SDI Courses
Spear Fishing
Guns
Pole Spears
Spear Heads
Technical Gear
Public Safety
Visual Inspection Tools
Saguaro Gift Card
Travel
Group Trips
Divi Bonaire 2021
Costa Rica
Cozumel 2021
Roatan
Adaptive Diving Trips
Cozumel Adaptive Diving Were Still Planning
Divi Bonaire 2021
Liveaboard Trips
Rentals
Service
Calendar
Blog
Contact Us
×
What are you looking for?
Home
About
Lessons
SDI Lessons
Forms and Registration
All ELearning Lessons
Scuba Certification Map
Learn To Dive For $99
Discover Scuba
SDI Refresher
Advanced Diver
SDI Rescue Diver Certification
SDI Divemaster Certification
Assistant Instructor
Instructor Certification
Specialties
PADI Lessons
Forms and Registration
All PADI ELearning Certifications
PADI Scuba Certification Map
Learn To Scuba Dive With PADI
Discover Scuba
PADI Refresher
Advanced Open Water
Rescue Diver
PADI Divemaster
Specialties
Disabled Diving
Disabled Diver Program
Disabled Diving
Disabled Diver Dive Buddy Program
Disabled Diver Instructor Program
Professional
ERDI Public Safety
ERD I
ERD II
SDI Visual Inspection Procedures
Visual Inspection Course
Visual Inspection Instructor Course
Eddy Current and Advanced Thread Inspection
Shop
SALE ITEMS
Packages
Rental Sales
Used Gear
Equipment
Masks
Prescription Dive Masks
Snorkels
Fins
Buoyancy Compensators
Regulators
Computers
Gauges
Snorkel Gear
Add On Gear
Cases & Bags
Knives
Photography
Lights
Scooters And ROVs
Accessories
Equipment Care
Flags & Floats
Retractors & Clips
Signaling Devices
Exposure Gear
Boots
Gloves
Hoods
Wet Suits
Dry Suits
Undergarments
Rash Guards
Training
PADI Materials
PADI Courses
SDI Materials
SDI Courses
Spear Fishing
Guns
Pole Spears
Spear Heads
Technical Gear
Public Safety
Visual Inspection Tools
Saguaro Gift Card
Travel
Group Trips
Divi Bonaire 2021
Costa Rica
Cozumel 2021
Roatan
Adaptive Diving Trips
Cozumel Adaptive Diving Were Still Planning
Divi Bonaire 2021
Liveaboard Trips
Rentals
Service
Calendar
Blog
Contact Us
0
Cart
Medical Release
Medical Release
Step 1 of 2
50%
Name
*
First
Last
Birthdate
*
Date Format: DD dash MM dash YYYY
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.
*
Yes
No
Could you be pregnant, or are you attempting to become pregnant?
*
Yes
No
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)
*
Yes
No
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...
*
Asthma, or wheezing with breathing, or wheezing with exercise?
Frequent or severe attacks of hayfever or allergy?
Frequent colds, sinusitis or bronchitis?
Any form of lung disease?
Pneumothorax (collapsed lung)?
Other chest disease or chest surgery?
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
Epilepsy, seizures, convulsions or take medications to prevent them?
Recurring complicated migraine headaches or take medications to prevent them?
Blackouts or fainting (full/partial loss of consciousness)?
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?
Dysentery or dehydration requiring medical intervention?
Any dive accidents or decompression sickness?
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
Head injury with loss of consciousness in the past five years?
Recurrent back problems?
Back or spinal surgery?
Diabetes?
Back, arm or leg problems following surgery, injury or fracture?
High blood pressure or take medicine to control blood pressure?
Heart disease?
Heart attack?
Angina, heart surgery or blood vessel surgery?
Sinus surgery?
Ear disease or surgery, hearing loss or problems with balance?
Recurrent ear problems?
Bleeding or other blood disorders?
Hernia?
Ulcers or ulcer surgery ?
A colostomy or ileostomy?
Recreational drug use or treatment for, or alcoholism in the past five years?
None of the above
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
*
Date Format: MM slash DD slash YYYY
Signature of Parent or Guardian (where applicable)
Date
Date Format: MM slash DD slash YYYY
X