The purpose of this medical questionnaire is to find out if a doctor should examine you before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving, it means that there is a pre-existing condition that may affect your safety while diving and it is necessary to seek the advice of a physician. Please read the following questions on your past or present medical history. If any of these items apply to you we must request that you consult a physician prior to participating in scuba diving.

• Could you be pregnant or are you attempting to become pregnant?
• Do you regularly take prescription or nonprescription medication?
  (with the exception of birth control or anti-malaria)
• Are you over 45 years of age and have one or more of the following?
  1. Currently smoke a pipe, cigars or cigarettes?
  2. Have a high cholesterol level
  3. Have a family history of heart attacks or strokes
  4. Are currently receiving medical care.
  5. High blood pressure.
  6. Diabetes mellitus, even if controlled by diet alone

Have you ever had or currently have ...

• Asthma,or wheezing with breathing, or wheezing with exercise?
• Frequent or severe attacks of hay fever or allergy?
• Frequent colds, sinusitis or bronchitis?
• Any form of lung disease?
• Pneumothorax (collapsed lung)?  
• Other chest disease or chest surgery?
• Behavioral health, mental or psychological problems  
• (Panic attack, fear of closed or open spaces)?
• Epilepsy, seizures, convulsions or take medications to prevent them?
• Recurring complicated migraine headaches or take medications to prevent them?
• Blackouts or fainting (full/partial loss of consciousness)?
• Do you frequently suffer from severe motion sickness (seasick, carsick etc.)?  
• Dysentery or dehydration requiring  medical interventions?
• History of diving accidents or decompression sickness?  
• Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 minutes)?
• Head injury with loss of consciousness in the past 5 years?
• Recurrent back problems?
• Back or spinal surgery?
• Diabetes?
• Back, arm or leg problems following surgery, injury or fracture?
• High blood pressure or take medications to control blood pressure?
• Heart disease?
• Heart attacks?
• Angina or heart surgery or blood vessel surgery?
• Sinus surgery?
• Ear disease, hearing loss or problems with balance?
• Recurrent ear problems?
• Bleeding or other blood disorders?
• Hernia?
• Ulcers or ulcer surgery?
• Colostomy or ileostomy?
• Recreational drug use or treatment for, or alcoholism in the past 5 years?