SDI Medical Questionnaire

Medical Questionnaire For Practitioners

Student Information
Students Full Name*
First Last
Student Birthdate*
DD dot MM dot YYYY
This person applying for training or is presently certified to engage in scuba (self-contained underwater breathing apparatus) diving. Your opinion of the applicant’s medical fitness for scuba diving is requested. There are guidelines attached for your information and reference.
Student Phone*
Physician
Physicians Impression*
- I find no medical conditions that I consider incompatible with diving.
- I am unable to recommend this individual for diving.
Remarks
Physicians signature or legal representative of medical practitioner*
Date*
DD dash MM dash YYYY
Physician Name*
First Last
Clinic/Hospital*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*

Please review the following PDF below regarding physical examinations for scuba divers.