Apneista Free-Diving Liability Release & Assumption Of Risk (Page 2 of 3) in pdf

Apneista medical statement

Important: Please read carefully before signing: Freediving is a strenuous activity carried

out in the underwater environment, which may, under certain conditions, increase your risk of

injury. This risk may be signiﬁcantly increased if you have certain physiological conditions.

This questionnaire has bean developed to make you aware of these conditions. The purpose

of a medical statement is to ﬁnd out, if you should be examined by a doctor before

participating in any freediving activity / events. Please read each question carefully and

answer them accurately. Please explain any “yes” answer on the backside of this

questionnaire. A positive answer will not necessarily exclude you from training with Apneista

or learning to freedive . But it will require a medical clearance from a physician. This form and

your answers will be kept conﬁdential.

Medical History

NEUROLOGICAL CONDITIONS - Any history of seizure disorder, stroke, brain surgery,

______

black out, severe migraine headaches, or aneurysm of the brain’s blood vessels.

CARDIOVASCULAR CONDITIONS - Heart attack, heart surgery, irregular heart beat,

______

uncontrolled elevated blood pressure.

PULMONARY CONDITIONS - Any history of spontaneous collapsed lung, collapsed lung

______

due to injury, cysts or air pockets of the lungs, damage to lung tissue, emphysema, or any

lung problem which interferes with your ability to breath.

EAR CONDITIONS - Permanent holes of the eardrums, history of ruptured eardrum,

______

severely impaired hearing or hearing loss in one or both ears, or ear surgery.

SINUS CONDITIONS - Tumor, polyps, cysts of the sinus cavities or nasal passages, sinus

______

surgery, or persistent sinus infections

ASTHMA - History of asthma or asthma attacks, history of wheezing caused by exercise,

______

anxiety, cold, fatigue, etc. Any conditions requiring medications and/or use of an inhaler

for control of wheezing.

DIABETES MELLITUS - Especially Type I Diabetes (Insulin dependent) or Type II Diabetes,

______

which requires insulin or oral medication for control. Any form of Diabetes that is

unstable or produces episodes of hypoglycemia (low blood sugar reactions) hyperglycemia

(extremely high blood sugar) or if there is related kidney disease, eye disease, heart

disease or blood vessel disease. Also, of history of elevated blood sugar during

pregnancy.

PREGNANCY - Are you presently pregnant?

______

FREEDIVING / SCUBA DIVING CONDITIONS - Previous history of a diving accident,

______

decompression sickness, decompression of the inner ear air embolus.

MEDICATION - Do you take any medication on a regular basis either over the counter or

______

prescribed by a physician?

GENERAL MEDICAL PROBLEMS - Any physical and / or emotional condition not

______

mentioned that might effect your safety in an underwater environment or affect your

judgment under times of physical or emotional stress.

Apneista Free-Diving Liability Release & Assumption Of Risk Page 2

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