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purpose of this questionnaire is to find out if you should be examined
by your doctor before participating in recreational diving.
If
you answer YES to any of the following we may request that
you consult with a physician prior to participating in scuba diving.
________________________________
Could
you be pregnant or are you attempting to become pregnant?
Do
you regularly take prescription or nonprescription medications?
(with the exception of birth control)
Are
you over 45 years of age and have one or more of the following:
1)
Currently smoke a pipe, cigars or cigarettes
2) Have a high cholesterol level
3) Have a family history of heart attacks or strokes
Have
you ever had or do you currently have:
Asthma,
or wheezing with breathing, or wheezing with exercise?
Frequent or severe attacks of hay fever or allergy?
Any form of lung disease?
Pneumothorax (collapsed lung)?
History of chest surgery?
Claustrophobia or agroaphobia (fear of closed or open spaces)?
Behavioral health problems?
Epilepsy, seizures, convulsions or take medications to prevent them?
Recurring migraine headaches or take medications to prevent them?
History of blackouts or fainting (full/partial loss of consciousness)?
Do you frequently suffer from motion sickness (seasick, carsick,
etc.)?
History of diving accidents or decompression sickness?
History of recurrent back problems?
History of back surgery?
History of diabetes?
History of back, arm or leg problems following surgery, injury or
fracture?
Inability to perform moderate
exercise (example: walk one mile
within 12 minutes)?
History of high blood pressure or take medicine to control blood
pressure?
History of any heart disease?
History of heart attacks?
Angina or heart surgery or blood vessel surgery?
History of ear or sinus surgery?
History of ear disease, hearing loss or problems with balance?
History of problems equalizing (popping) ears with airplane or mountain
travel?
History of bleeding or other blood disorders?
History of any type of hernia?
History of ulcers or ulcer surgery?
History of colostomy?
History of drug or alcohol abuse?
If
you answered YES to any of the questions, you may have to
attend a physician who must sign a Medical Statement.
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