Medical Questionnaire

To the Participant:

The purpose of this medical questionnaire is to find out if you should be examined by a doctor before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of a physician.

Please answer the following questions on your past and 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. Your instructor will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to a physician.

_____ Do you currently have an ear infection?

Do you have a history of ear or sinus surgery?

Are you currently suffering from a cold, congestion, sinusitis or bronchitis?

Do you have a history of respiratory problems, severe attack of hayfever or allergies, or lung disease?

Have you had a collapsed lung (pneumothorax) or history of chest surgery?

Do you have active asthma or history of emphysema or tuberculosis?

Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?

Do you have behavioral health, mental or psychological problems or a nervous system disorder?

Are you or could you be pregnant?

Do you have a history of colostomy?

Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?

Do you have a history of high blood pressure, angina, or take medication to control blood pressure

Are you over 45 and have a family history of heart attack or stroke? Do you have a history of bleeding or other blood disorders? Do you have a history of diabetes?

Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?

Do you have a history of back, arm or leg problems following an injury, fracture or surgery?

Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.



Participant Signature


Do you have a history of ear disease, hearing loss or problems with balance?

Parent/Guardian Signature (where applicable)


RODUCT NO. 10194 (9/02) Version 2.1 pdf

© International PADI, Inc. 2002

Guide To Scuba Diving

Guide To Scuba Diving

Many people think that space is our final frontier and that is not entirely true. While it is more difficult to get to outer space, we probably know more about the various planetsand environments in space than wedo about what lies beneath the surface of our oceans.

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