Medical Assessment Form For Fitness To Dive (Page 4 of 6) in pdf

Medical Assessment Form For Fitness To Dive Page 4

Medical Assessment

Form No.:

CFT/IUC409

Sport Diving

Issue No.:

4.2

Dated:

01-Sep-2017

Irish Underwater Council

SECTION B: TO BE COMPLETED BY THE MEDICAL EXAMINER

Medical Examination

Height

Weight

Visual Acuity

Blood pressure Pulse

bpm.

R6/

Corrected 6/

Regular

L6/

Corrected 6/

Irregular

Urinalysis

PEFR

l/min &

% of expected PEFR Chest X-Ray (If indicated)

Glucose

Date

Protein

Place

Blood

Result

BMI less than 30 – if

All asthmatics must have respiratory

Cardiovascular Risk score

over 30 please consult

function tests as per UKDMC /BTS

( SCORE)

with IUC Medical

guidelines.

If IHD score elevated

Advisor

investigate

If clinical examination abnormal, enter in diver’s log book and on certificate

Notes on abnormalities

Clinical Examination / Assessment

Normal

Abnormal

Nose Septum Airway

Mouth, throat teeth

External auditory canal

Tympanic membrane

Middle ear auto-inflation

Neurological

Eye movements

Pupillary reflexes

Limb Reflexes

Finger – nose

Sharpened Romberg

Abdomen

Chest

Cardiac auscultation

Other abnormalities

Page 4 of 6

Medical Assessment Form For Fitness To Dive Page 4

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