Veteran Owned and Operated

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Medical History for Divers

The purpose of completing the medical history for divers and proceeding with the medical exam is to obtain medical data for determination of medical fitness for diving in addition to evaluating the medical risk YOU assume. Disclosure of any and all information is purely voluntary; however, failure to provide the requested information increases your own risk associated with diving. Attestation of your responses as true and complete is required.

All information disclosed will be considered strictly confidential. Any disclosures require the specific written consent of the person to whom the information pertains or as otherwise permitted by regulation (obligation to report etc.). A general authorization for the release of medical or other information collected is not sufficient to release any confidential information.

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Do you currently take ANY medications?*
Do you currently take ANY medications?
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Do you have any allergies?*
Do you have any allergies?
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Do you carry an Epi-Pen?*
Do you carry an Epi-Pen?
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PAST MEDICAL HISTORY: Have you EVER had the following?

1. Adverse reaction to medication*
1. Adverse reaction to medication
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2. Tuberculosis or positive TB test*
2. Tuberculosis or positive TB test
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3. Asthma or any breathing difficulty*
3. Asthma or any breathing difficulty
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4. Used or have been prescribed an inhaler*
4. Used or have been prescribed an inhaler
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5. Plates, screws, or rods or pins in any bone*
5. Plates, screws, or rods or pins in any bone
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6. Sugar, albumin or blood in the urine*
6. Sugar, albumin or blood in the urine
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7. Tumor, growth, cyst, or cancer*
7. Tumor, growth, cyst, or cancer
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8. Aneurysm, frequent or severe headaches*
8. Aneurysm, frequent or severe headaches
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9. Seizures, convulsions, epilepsy, or fits*
9. Seizures, convulsions, epilepsy, or fits
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10. Treated in a decompression chamber*
10. Treated in a decompression chamber
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11. Pain or pressure in the chest*
11. Pain or pressure in the chest
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12. Palpitation, pounding heart or abnormal heartbeat*
12. Palpitation, pounding heart or abnormal heartbeat
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13. Heart murmur or other disorder*
13. Heart murmur or other disorder
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14. Abnormal heart anatomy or patent foramen ovale*
14. Abnormal heart anatomy or patent foramen ovale
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15. Diabetes*
15. Diabetes
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16. High cholesterol*
16. High cholesterol
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17. Stroke*
17. Stroke
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18. Heart Disease*
18. Heart Disease
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19. Parent or sibling with condition indicated in 15-18*
19. Parent or sibling with condition indicated in 15-18
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20. Other neurologic disorder or injury*
20. Other neurologic disorder or injury
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PAST MEDICAL HISTORY: Have you had the following in the LAST TEN YEARS?

21. Thyroid trouble or goiter*
21. Thyroid trouble or goiter
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22. Eye disorder or trouble*
22. Eye disorder or trouble
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23. Surgery to correct vision (i.e. RK, PRK, LASIK)*
23. Surgery to correct vision (i.e. RK, PRK, LASIK)
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24. Recurrent back pain or any back problem*
24. Recurrent back pain or any back problem
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25. Nerve injury, numbness, tingling or sensitive areas*
25. Nerve injury, numbness, tingling or sensitive areas
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26. Loss of finger or toe*
26. Loss of finger or toe
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27. Knee trouble (locking, giving out, pain, injury)*
27. Knee trouble (locking, giving out, pain, injury)
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28. Leg cramps*
28. Leg cramps
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29. Painful or swollen joints*
29. Painful or swollen joints
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30. Arthritis, rheumatism, tendonitis or bursitis*
30. Arthritis, rheumatism, tendonitis or bursitis
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31. Artificial joint or other deformity*
31. Artificial joint or other deformity
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32. Bone fracture or deformity*
32. Bone fracture or deformity
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33. Stomach or intestinal trouble*
33. Stomach or intestinal trouble
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34. Jaundice, hepatitis or liver disease*
34. Jaundice, hepatitis or liver disease
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35. Hernia*
35. Hernia
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36. Rectal disease, hemorrhoids, bleeding from rectum*
36. Rectal disease, hemorrhoids, bleeding from rectum
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37. Shortness of breath or wheezing*
37. Shortness of breath or wheezing
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38. Sinusitis, bronchitis or frequent colds*
38. Sinusitis, bronchitis or frequent colds
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39. Kidney, bladder or urination problems*
39. Kidney, bladder or urination problems
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40. Head injury, memory loss or amnesia*
40. Head injury, memory loss or amnesia
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41. Concussion or period of unconsciousness*
41. Concussion or period of unconsciousness
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42. Dizziness or fainting spells*
42. Dizziness or fainting spells
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43. Prolonged bleeding, blood clot or embolism*
43. Prolonged bleeding, blood clot or embolism
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44. High or low blood pressure*
44. High or low blood pressure
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45. Depression, anxiety or claustrophobia*
45. Depression, anxiety or claustrophobia
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46. Received counseling of any type*
46. Received counseling of any type
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47. Been evaluated or treated for a mental condition*
47. Been evaluated or treated for a mental condition
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48. Attempted or planned suicide*
48. Attempted or planned suicide
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49. Inability to focus or pay attention*
49. Inability to focus or pay attention
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50. Ear infection*
50. Ear infection
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CURRENT MEDICAL HISTORY: Do you CURRENTLY have any of the following?

51. Severe tooth or gum trouble*
51. Severe tooth or gum trouble
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52. Wear glasses or contact lenses*
52. Wear glasses or contact lenses
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53. Lack of vision in either eye*
53. Lack of vision in either eye
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54. Hay fever or allergic rhinitis*
54. Hay fever or allergic rhinitis
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55. Ear, nose or throat trouble*
55. Ear, nose or throat trouble
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56. Hearing loss or wear a hearing aid*
56. Hearing loss or wear a hearing aid
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57. Impaired use of arms, hands, legs or feet*
57. Impaired use of arms, hands, legs or feet
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58. Foot problems*
58. Foot problems
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59. Use of prosthetic / corrective devices or braces*
59. Use of prosthetic / corrective devices or braces
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60. Frequent indigestion or heartburn*
60. Frequent indigestion or heartburn
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61. Skin disease (i.e. acne, eczema, psoriasis)*
61. Skin disease (i.e. acne, eczema, psoriasis)
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62. Recent unexplained weight loss or gain*
62. Recent unexplained weight loss or gain
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63. Motion sickness (kinetosis)*
63. Motion sickness (kinetosis)
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64. Difficulty distinguishing colors or seeing at night*
64. Difficulty distinguishing colors or seeing at night
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65. Difficulty performing moderate to heavy exercise*
65. Difficulty performing moderate to heavy exercise
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66. Currently pregnant/may be pregnant (women only)*
66. Currently pregnant/may be pregnant (women only)
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67. Indicate the type and frequency of use for the following

a. Alcohol*
a. Alcohol
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b. Tobacco / Nicotine*
b. Tobacco / Nicotine
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c. Recreational drugs (including marijuana)*
c. Recreational drugs (including marijuana)
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Have you ever had the following as a result of diving?

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68a. Ear or sinus squeeze*
68a. Ear or sinus squeeze
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68b. Inability to equalize middle ear pressure*
68b. Inability to equalize middle ear pressure
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68c. Ruptured ear drum*
68c. Ruptured ear drum
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68d. Vertigo (dizziness)*
68d. Vertigo (dizziness)
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68e. Loss of consciousness or asphyxia*
68e. Loss of consciousness or asphyxia
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68f. Lung squeeze or collapsed lung (pneumothorax)*
68f. Lung squeeze or collapsed lung (pneumothorax)
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68g. Near drowning*
68g. Near drowning
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68h. Arterial gas embolism*
68h. Arterial gas embolism
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68i. Oxygen (O2) toxicity*
68i. Oxygen (O2) toxicity
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68j. Carbon dioxide (CO2) toxicity*
68j. Carbon dioxide (CO2) toxicity
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68k. Type I DCS (pain only, itching, rash, swelling)*
68k. Type I DCS (pain only, itching, rash, swelling)
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68l. Type II DCS (Neurological Symptoms)*
68l. Type II DCS (Neurological Symptoms)
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By signing below, I confirm that I have disclosed all information associated with my medical history to the best of my knowledge.

Sign Above
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