Medical Questionnaire Template printable pdf download

INTERNATIONAL ASSOCIATION OF NITROX AND TECHNICAL DIVERS/IAND, INC.

Medical Questionnaire

INSTRUCTOR COPY

Student Information - Please Print Legibly

Name :__________________________________________________________________________

Birth Date: _____/_________/_________

MESSAGE TO THE MEDICAL EXAMINER

Technical Scuba diving activities with compressed air, oxygen-enriched air (Nitrox), oxygen, helium and/or Trimix are physically strenuous

and will cause exertion of the student during the diving course and they may be injured or killed as the result of decompression sickness,

embolism, marine life injuries, barotraumas/hyperbaric injuries that can occur requiring treatment in a recompression chamber, heart attacks,

panic hyperventilation, oxygen toxicity, inert gas narcosis, drowning or any other organic malfunction that may occur.

Please read each question carefully and answer them accurately. Please explain any “yes” answers in the space provided at the bottom of this

questionnaire. This form and your answers will be kept confidential. A positive answer will not necessarily exclude you from participating in the

IANTD Technical Diving Program.

NEUROLOGICAL CONDITIONS:

Especially any history of seizure disorder, stroke, brain surgery, black out, severe migraine

YES

headaches, or aneurysm of the brain’s blood vessels.

2. CARDIOVASCULAR CONDITIONS:

Especially heart attack, heart surgery, irregular heart beat, uncontrolled elevated blood

YES

pressure (hypertension).

3. PULMONARY CONDITIONS:

Especially a history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets

YES

of the lungs, severe damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breathe.

4. EAR CONDITIONS

: Permanent holes of the eardrums, history of ruptured eardrum, permanent tubes in eardrums, severely impaired

YES

hearing or hearing loss in one ore both ears, or major ear surgery.

5. SINUS CONDITIONS:

Tumor, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or persistent sinus

YES

infection.

6. ASTHMA:

History of asthma or asthma attacks. Any history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any condition

YES

requiring medication and/or use of inhaler for control of wheezing.

7. DIABETES MELLITUS:

Especially Type I Diabetes (Insulin dependent) or Type II Diabetes, which require insulin or oral medication for

control. Any form of Diabetes that is unstable, “brittle” or episodes of hypoglycemia (low blood sugar reactions), Hyperglycemia (extremely

high blood sugar with ketosis) or if there is related kidney disease, eye disease, heart disease or blood vessel disease. Also any

YES

history of elevated blood sugar or elevated blood during pregnancy.

8. PREGNANCY: If

YES

you are presently pregnant or may become pregnant before completing your scuba course.

9. SCUBA DIVING CONDITIONS:

Previous history of a diving accident, decompression sickness, decompression of the inner ear

YES

or air embolus.

10. MEDICATION:

YES

Any medication taken on a regular basis either over-the -counter or prescribed by a physician.

11. GENERAL MEDICAL PROBLEMS:

Any physical and/or emotional condition not mentioned that might affect the students safety

YES

in an underwater environment or affect the students judgment under times of physical stress.

12. PLEASE EXPLAIN ANY “YES” ANSWER FOR QUESTIONS 1 THROUGH 11.

First list item number and then provide the explanation. Use the back of this paper, if necessary. ___________________________________________

I certify that I have answered the above questions accurately and honestly.

Signed: ______________________________________________ Date: _________/_________/_________

Witnessed by: ________________________________________ Date: _________/_________/_________

If under 18 years of age student’s parent or guardian is also required to certify the form’s accuracy by co-

signing the form.

Signed: ______________________________________

Date: __________/__________/_________

_______ Student Cleared for Class

_________ Student Requires Medical Clearance

Instructor’s Signature: ____________________________________Date: _________/__________/_________

Medical Questionnaire Template

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