Diver Medical | Participant Questionnaire

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Diver Medical | Participant Questionnaire

This form is based on the Royal Decrete 550/2020, of 2nd of June, which is regulating the medical suitability to participate in recreational scubadiving or freediving training or activity in Spain.

You will receive the results by email. In case you will need to get a medical certificate from a doctor, you find attached to the email the necessary forms for your medic.

Personal data

Mr. Mrs.

Age

Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which canRecreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which canbe hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated bya physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. Ifyou have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If youare feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating indive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving.This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuingeducation. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.

Are you pregnant, or attempt to become pregnant?

Yes No

If you are pregnant, or attempting to become pregnant, do not dive!

We will meet again in 9 months.

1. have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.

Yes No

I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).

Yes No

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.

Yes No

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack orA problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack orstroke, OR am taking medication for any heart condition.

Yes No

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.

Yes No

A diagnosis of COVID-19.

Yes No

2. I am over 45 years of age.

Yes No

I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.

Yes No

I have a high cholesterol level.

Yes No

I have high blood pressure.

Yes No

I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heartI have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heartdisease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Yes No

3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.

Yes No

4. I have had problems with my eyes, ears, or nasal passages/sinuses.

Yes No

I have/have had:

Sinus surgery within the last 6 months.

Yes No

Ear disease or ear surgery, hearing loss, or problems with balance.

Yes No

Recurrent sinusitis within the past 12 months.

Yes No

Eye surgery within the past 3 months.

Yes No

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes No

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

Yes No

I have/have had:

Head injury with loss of consciousness within the past 5 years.

Yes No

Persistent neurologic injury or disease.

Yes No

Recurring migraine headaches within the past 12 months, or take medications to prevent them.

Yes No

Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.

Yes No

Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Yes No

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.

Yes No

I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Yes No

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.

Yes No

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.

Yes No

An addiction to drugs or alcohol requiring treatment within the last 5 years.

Yes No

8. I have had back problems, hernia, ulcers, or diabetes.

Yes No

I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.

Yes No

Back or spinal surgery within the last 12 months.

Yes No

Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.

Yes No

An uncorrected hernia that limits my physical abilities.

Yes No

Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Yes No

9. I have had stomach or intestine problems, including recent diarrhea.

Yes No

I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.

Yes No

Dehydration requiring medical intervention within the last 7 days.

Yes No

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.

Yes No

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).

Yes No

Active or uncontrolled ulcerative colitis or Crohn’s disease.

Yes No

Bariatric surgery within the last 12 months.

Yes No

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).

Yes No

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Diver Medical | Participant Questionnaire
Safe Diving form
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Find medical referees (UKDMC) UK
Youth diving responsability and risk acknowledgement
Youth Diving Information Flip Chart

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Diver Medical | Participant Questionnaire

Diver Medical | Participant Questionnaire

Directions

If you are pregnant, or attempting to become pregnant, do not dive!

I have/have had:

I am over 45 years of age AND:

I have/have had:

I have/have had:

I have/have had:

I have/have had:

I have had: