This form is mandatory for every Scuba Diving activity.

Diver Medical

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.


The undersigned


**If you answered YES to questions 3, 5 or 10 above or to any of the questions on second stage, please read and agree to the statement above by signing and dating it and take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

Participant Questionnaire Continued

Box A

I have/have had:

Box B

I am over 45 years of age AND:

Box C

I have/have had

Box D

I have/have had

Box E

I have/have had

Box F

I have/have had

Box G

I have had

* Physician’s medical evaluation required

Diver Medical

Physician‘s Evaluation Form

**If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

Participant Statement: 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 for my failure to disclose any existing or past health conditions.