SSI - Open Water Diver

MEDICAL STATEMENT Participant Record (Confidential Information) Divers Medical Questionnaire To the Participant: The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities. Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to at participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to your physician. _____ _____ _____ Could you be pregnant, or are you attempting to become pregnant? Are you presently taking prescription medications? (with the exception of birth control or anti-malarial) Are you over 45 years of age and can answer YES to one or more of the following? * currently smoke a pipe, cigars or cigarettes 
 * have a high cholesterol level 
 * have a family history of heart attack or stroke 
 * are currently receiving medical care 
 * high blood pressure 
 * diabetes mellitus, even if controlled by diet alone 
 Dysentery or dehydration requiring medical intervention? Any dive accidents or decompression sickness? Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)? Head injury with loss of consciousness in the past five years? Recurrent back problems?
Back or spinal surgery?
Diabetes? Back, arm or leg problems following surgery, injury or fracture? High blood pressure or take medicine to control blood pressure? Heart disease?
Heart attack? Angina, heart surgery or blood vessel surgery? Sinus surgery? Ear disease or surgery, hearing loss or problems with balance? Recurrent ear problems? Bleeding or other blood disorders? Hernia? Ulcers or ulcer surgery ? A colostomy or ileostomy? Recreational drug use or treatment for, or alcoholism in the past five years? Have you ever had or do you 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)? Frequent or severe suffering from motion sickness (seasick, carsick, etc.)? The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.