Medical Questionnaire Template Page 2

WARNING: Oral or total systemic decongestants, Trans-

Derm, or oral sea sickness medications, nicotine patches, all

legal or non-legal drugs, individually or in combination of,

MAY cause harmful, if not fatal, reactions underwater,

especially if taken too soon before diving.

(student’s

name)

_____________________________________,

acknowledge that I have read the above warning and that I

understand, and take responsibility for my actions as regards my

use or misuse of any and all drugs during this course of scuba

instruction.

Student signature ___________________ date _______/________/________

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Parent category: Life