Sdi Physician Form printable pdf download

STUDENT

Please print legibly

Name:______________________________________________________ Birth Date:____________ Age:______

First

Initial

Last

Mailing Address:_____________________________________________________________________________

_____________________________________________________________________________

City:___________________________________________ State/ Province:_______________________________

Country:_______________________________________ Zip / Postal Code:______________________________

Phone: (_______)_______________________________ Fax: (_______)_________________________________

Name and address of your family or primary care physician

Physician:__________________________________________ Clinic/ Hospital:___________________________

Address:____________________________________________________________________________________

City

State

Zip

Phone: (____)______________________________________ Date of last physical examination: ____ /____/____

mm / dd / yy

Name of examiner:__________________________________ Clinic/ Hospital:____________________________

Address:_____________________________________________________ Phone: (______)_________________

Were you ever required to have a physical for diving? Yes

If so, when? _________________________

PHYSICIAN

This person is an applicant for training or is presently certified to engage in scuba (self

contained underwater breathing apparatus) diving. Your opinion of the applicant’s medical

fitness for scuba diving is requested

Physician’s impression:

____ I find no medical conditions that I consider incompatible with diving.

____ I am unable to recommend this individual for diving.

Remarks: __________________________________________________________________________________

__________________________________________________________________________________

Physician:___________________________________________ Clinic/ Hospital:__________________________

Address:____________________________________________________________________________________

City

State

Zip

Phone: (________)__________________________ Fax: (________)________________________________

Physician's Signature:_______________________________________________ Date ______/______/______

mm /

International Training, Inc.● 18 Elm Street ● Topsham ME 04086

Phone: (207) 729-4201● Fax: (207) 729-4453

Sdi Physician Form