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11APPENDIX 2
AAUS MEDICAL EVALUATION OF FITNESS FOR SCUBA DIVING REPORT
_________________________________________________________ _______________________________________
Name of Applicant (Print or Type)
Date of Medical Evaluation (Month/Day/Year)
To The Examining Physician: Scientific divers require periodic scuba diving medical examinations to assess their fitness to
engage in diving with self-contained underwater breathing apparatus (scuba). Their answers on the Diving Medical History
Form may indicate potential health or safety risks as noted. Scuba diving is an activity that puts unusual stress on the
individual in several ways. Your evaluation is requested on this Medical Evaluation form. Your opinion on the applicant's
medical fitness is requested. Scuba diving requires heavy exertion. The diver must be free of cardiovascular and respiratory
disease (see references, following page). An absolute requirement is the ability of the lungs, middle ears and sinuses to
equalize pressure. Any condition that risks the loss of consciousness should disqualify the applicant. Please proceed in
accordance with the AAUS Medical Standards (Sec. 6.00). If you have questions about diving medicine, please consult with
the Undersea Hyperbaric Medical Society or Divers Alert Network.
TESTS: THE FOLLOWING TESTS ARE REQUIRED:
DURING ALL INITIAL AND PERIODIC RE-EXAMS (UNDER AGE 40):
Medical history
•
Complete physical exam, with emphasis on neurological and otological components
•
Urinalysis
•
Any further tests deemed necessary by the physician
•
ADDITIONAL TESTS DURING FIRST EXAM OVER AGE 40 AND PERIODIC RE-EXAMS (OVER
AGE 40):
Chest x-ray (Required only during first exam over age 40)
•
Resting EKG
•
1
Assessment of coronary artery disease using Multiple-Risk-Factor Assessment
•
(age, lipid profile, blood pressure, diabetic screening, smoking)
2
Note: Exercise stress testing may be indicated based on Multiple-Risk-Factor Assessment
PHYSICIAN’S STATEMENT:
01 Diver IS medically qualified to dive for:
2 years (over age 60)
3 years (age 40-59)
5 years (under age 40)
02 Diver IS NOT medically qualified to dive:
Permanently
Temporarily.
I have evaluated the abovementioned individual according to the American Academy of Underwater Sciences medical
standards and required tests for scientific diving (Sec. 6.00 and Appendix 1) and, in my opinion, find no medical conditions
that may be disqualifying for participation in scuba diving. I have discussed with the patient any medical condition(s) that
would not disqualify him/her from diving but which may seriously compromise subsequent health. The patient understands
the nature of the hazards and the risks involved in diving with these conditions.
____________________________________________________ MD or DO
_______________________________
Signature
Date
________________________________________________________________________________________________
Name (Print or Type)
_______________________________________________________________________________________________
Address
____________________________________
____________________________________________________
Telephone Number
E-Mail Address
My familiarity with applicant is: _____This exam only
_____Regular physician for _______ years
My familiarity with diving medicine is: ________________________________________________________________
Revised 12/09
Page 59
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