Medical Questionnaire

Medical Statement

PARTICIPANT RECORD - CONFIDENTIAL INFORMATION

Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by Sydney Dive Safari.

Read and discuss this statement prior to signing it. You must complete this Medical Statement, which includes the medical-history section, to enrol in the scuba training program. If you are a minor, you must have this Statement signed by a parent. Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there are dangers.

To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor and the Instructor before participation in this program. You will also need to learn from the Instructor the important safety rules regarding breathing and equalisation while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified Instructor to use it safely.

If you have any additional questions regarding this Medical Statement or the Medical History section, review them with your Instructor before signing.

Medical History

To the Participant:

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 pre-existing condition that may affect your safety while diving and you must seek the advice of a licensed medical practitioner.

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. Please download a copy of the RSTC Medical Statement and Guidelines for recreational scuba diver’s physical examination to take to your licensed medical practitioner.

  • ___

  • • currently smoke a pipe, cigars, or cigarettes • have a high cholesterol level • have a family history of heart attacks or strokes • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone
  • HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...

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