Medical Assessment Form For Fitness To Dive Page 2
ADVERTISEMENT
1
2
3
4
5
6Medical Assessment
Form No.:
CFT/IUC409
Sport Diving
Issue No.:
4.2
Dated:
01-Sep-2017
Irish Underwater Council
Pleurisy or severe chest pain
Coughing up blood
Chronic or persistent cough
TB (Tuberculosis)
Pneumothorax (“Collapsed lung”)
Frequent chest colds
Asthma or wheezing
Use an inhaler
Other chest complaint
Operation on chest, heart or lungs
Indigestion, peptic ulcer or acid reflux
Vomiting blood or passing red or black motions
Recurrent vomiting or diarrhoea
Jaundice, hepatitis, or liver disease
Severe loss of weight
Hernia or rupture
Major joint or back injury
Limitation of movement
Fractures (broken bones)
Paralysis or muscle weakness
Kidney or bladder disease
Any chronic disease (see note below)
Syphilis
Diabetes
Blood disease or bleeding problem
Operations
In hospital for any reason
Life insurance rejected
A job or license refused on medical grounds
Unable to work for medical reasons
Other illness or injury or any other medical
conditions
Females Only:
Are you now pregnant or are you planning to
be?
I certify that the above information is true and complete to the best of my knowledge and I hereby
authorise Dr
to give medical opinion as to my fitness, or temporary or
permanent unfitness to dive to my diving officer. I also authorise him or her to obtain or supply
medical information regarding me to other doctors as may be necessary for medical purposes in my
personal interest.
Signed:
Date:
Note
Any chronic disease, such as hepatitis A, B, C, HIV (AIDS), Tuberculosis (TB), may increase your
risks from diving. If you have any chronic disease please discuss it with your doctor who will then be
able to advise you whether you will be at increased risk.
Page 2 of 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal