This form is mandatory for every activity made with us.

Health Declaration Form / COVID-19

Read this statement prior to signing it. You must complete this additional medical questionnaire to enrol in a diver training program or to participate in any diving activity. If you are a minor, you must have this statement signed by your parent or guardian.

Informations

The undersigned


Diver Medical Questionnaire

The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Please answer the following questions with a YES or NO. If you are not sure, answer YES. A positive response means that there may be a preexisting condition that could affect your safety while diving. If any of these items apply to you, we must request that you consult with a physician, preferably a specialist in diving medicine, prior to participating in diving activities.

Within the 40 days immediately preceding the date of this Health Declaration Form, have you:




Diver Medical Questionnaire




Please Note


COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalesce before returning to full activities – a process that can take weeks or months depending on symptom severity.

Medical Recommendation

• Divers who have tested positive with COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.

• Divers who have had symptomatic COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a diving medicine specialist.

• Divers who have been hospitalised with or because of pulmonary symptoms in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted or coordinated by a diving medicine specialist, with complete pulmonary function testing (at least FVC, FEV1, PEF25-50-75, RV and FEV1/FVC, and an exercise test with peripheral oxygen saturation measurement) as well as a high resolution CT scanning of the lungs.

• Divers who have been hospitalised with or because of cardiac problems in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted or coordinated by a diving medicine specialist with cardiac evaluation, including echocardiography and exercise test (exercise electrocardiography).

General Recommendation

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe / Divers Alert Network).

References

Return to Diving Post COVID-19

issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.


Diving after COVID-19 pulmonary infection

A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG).


Recreational and professional diving after the Coronavirus disease (COVID-19) outbreak

Position statement of EUBS & ECHM.



The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them. The Form has been developed by the DAN Europe Medical Division team, based on information available as of May 2020. The epidemiological situation is constantly evolving.As a result, this document may be subject to changes and updates.



Hi [field id="field_385d2ed"], thank you to have spent a bit of time to fill up our Health Declaration COVID-19 form. Your submission has been saved and will bre printed out form our staff. This form will be even stored on our Database.
Health Declaration Form / COVID-19 Form
General informations
Date: [field id="field_86c9dc0"]
Activity: [field id="field_a1448d4"]
That will be made with:
Archeo Diving Snc
Via degli Oleandri 10
09049 Villasimius (Cagliari)
www.archeodiving.it
[email protected]
Name: [field id="field_385d2ed"]
Surname: [field id="field_942490e"]
E-Mail: [field id="email"]
Telephone: [field id="field_e41f9c7"]
Address:
[field id="field_6242632"], [field id="field_aa0e68b"]
City: [field id="field_f423267"]
Country region: [field id="field_60d5d67"]
ZIP code: [field id="field_31b4274"]
Country: [field id="field_8da28d8"]
[field id="field_385d2ed"] [field id="field_942490e"]
I DECLARE
[field id="field_86c9dc0"]

TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR– SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_64626ab"]
[field id="field_86c9dc0"]

EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_bf8c387"]
[field id="field_86c9dc0"]

BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_5733231"]
[field id="field_86c9dc0"]

BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_f348aa3"]
[field id="field_385d2ed"] [field id="field_942490e"]
I ALSO DECLARE
[field id="field_86c9dc0"]

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by ARCHEO DIVING STAFF, and will take all reasonable preventive steps that may be recommended by ARCHEO DIVING STAFF, or any relevant public authority.

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_502619d"]
[field id="field_86c9dc0"]

I WILL accept and observe all instructions by ARCHEO DIVING STAFF regulations, required to help prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities.

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_760f7fe"]
[field id="field_86c9dc0"]

I ACKNOWLEDGE and ACCEPT that this declaration will be considered as my consent to ARCHEO DIVING STAFF o retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_809f414"]
[field id="field_86c9dc0"]

14 - To have provided correct and truthful information on every choice that has been chosen and / or on every field that has been filled up on this form

[field id="field_385d2ed"] [field id="field_942490e"] declare: [field id="field_000ffac"]
Date:

...........................................................................................
Sign:

...........................................................................................

THANKYOU!

Your form has been submitted successfully.

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Archeo Diving SNC

Via Degli Oleandri 10
09049 Villasimius (Cagliari) – Italy

+39 346 301 6432

+39 320 153 8591