Association Of Diving Contractors International Medical History Form
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4Association of Diving Contractors International
MEDICAL HISTORY FORM
Employer
Job Title
Date
1. Last Name
First Name
Middle Name
2. Date of Birth
3. Gender
4. SSN or PASSPORT No.
5. Address (Number, Street)
6. City
7. State
8. Zip Code
9. Area Code – Phone Number
(
)
10. Emergency Contact Person – Relationship – Address – Telephone Number
11. Cell Phone Number
(
)
12. MEDICAL HISTORY: Have you ever had or been treated for (positive answers must be explained below):
Yes
No
Yes
No
Yes
No
Convulsions or Seizures
Cardiac Angiogram or ECHO
Herniated Disc or Sciatica
Epilepsy
PFO Repair
Shoulder Injury
Concussion or Head Injury
High Blood Pressure
Elbow Injury
Disabling Headaches
Asthma or Wheezing
Arm/wrist/hand Injury
Loss of Balance/Dizziness
Coughing up Blood
Hip/Leg/Ankle Injury
Severe Motion Sickness
Tuberculosis
Knee Injury or “Trick Knee”
Unconsciousness
Shortness of Breath
Foot Trouble or Injuries
Fainting Spells
Chronic Cough
Dislocations
Wear Contacts/Glasses
Pneumothorax
Swollen Joints
Color Vision Defect
Lung Disease or Surgery
Broken Bones or Fractures
Eye Disease or Injury
Gallbladder Disease or Stones
Varicose Veins
Eye Surgery
Stomach Trouble or Ulcers
Muscle Disease or Weakness
Hearing Loss
Stomach Bleeding
Numbness or Paralysis
Ear Disease or Injury
Frequent Indigestion
Sleep Disorders
Ear Surgery
Jaundice
Diabetes
Perforated Eardrum
Liver Disease or Hepatitis
Goiter or Thyroid Disease
Difficulty Clearing
Rectal Bleeding/Blood in Stools
Blood Disease
Nose Bleed
Hemorrhoids (Piles)
Anemia: Sickle Cell or Other
Airway Obstruction
Gas Pains
Skin Rash or Disease
Hay Fever or Allergies
Crohn’s Disease/Ulcerative Colitis
Staph Infections
Chest Pain
Rupture or Hernia
Tumor or Cancer
Heart Murmur
Kidney Disease
Claustrophobia
Rheumatic Fever
Kidney Stones
Mental Illness/Depression/Anxiety
Heart Attack
Protein, Sugar or Blood in Urine
Nervous Breakdown
Abnormal Heart Rhythm
Joint Pain/Arthritis
Any Sexually Transmitted Disease
Heart Disease
Back Strain or Injury
Contagious Disease
Cardiac Stent or Angioplasty
Spine Problems
Other Illness or Injury or Any Other
Medical Condition
For Females ONLY
Painful Menses
Irregular Menses
Pregnancy
Last Menstrual Period _____________________
PLEASE EXPLAIN THE DETAILS OF EACH ITEM CHECKED YES
13. LIST ALL SURGERIES
YEAR
14. LIST ALL HOSPTALIZATIONS
YEAR
15. LIST ALL INJURIES
YEAR
16. LIST ALL MEDICATIONS, PRESCRIPTION OR OVER THE COUNTER
17 ANSWER THE FOLLOWING QUESTIONS:
YES
NO
YES
NO
Every Item Checked Yes Must Be Fully Explained Below
Have you ever resigned, been terminated, or changed jobs for medical
Do you have any physical defects or any partial disabilities?
reasons?
Have you ever been rejected or rated for insurance, employment, license, or
Have you ever been dismissed from employment because of excess use of
armed forces for health reasons?
drugs or alcohol?
Have you ever had illnesses, injuries, or lost time accidents from any work
Do you have any allergies or reactions to food, chemicals, drugs, insect
that you have done?
stings, or marine life?
Have you been advised to have a surgical operation or medical treatment that
Are you presently under the care of a physician? Give physician’s name
has not been done?
and address on the next page.
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