Medical Assessment For Diving

All students participating in pool dives or open water dives at Aquatic Adventures, Inc. are required to complete a medical assessment certifying their fitness for diving. This confidential statement asks students to identify any medical issues they currently have that could affect their ability to dive. While declaring a medical condition does not preclude you from participating in scuba training, it does mean that you will need a medical doctor certify your medical fitness. This is done by having your doctor complete and sign the RSTC Medical Statement prior to your first day of class.

Please read through the sample form below before you register for class. If you will need to answer YES to any item, download the RSTC Medical Statement here and bring it to your doctor. Then provide the signed form to Aquatic Adventures no later than your first day of class. Without a doctor's signature verifying your medical fitness for scuba diving, you WILL NOT be allowed to participate in scuba training. There are no exceptions to this rule.

Please note that an RSTC Medical Statement completed by your doctor is good for 12 months assuming your medical condition does not change. If your medical condition changes or you have not had an RSTC Medical Statement signed by your doctor in the last 12 months, a new form must be completed.

Divers Medical Questionnaire

To the Participant:

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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 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

Note to Women: If you are pregnant, or attempting to become pregnant, do not dive.

1. _____ I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. YES (If yes, go to Section A) or NO

2. _____ I am over 45 years of age. YES (If yes, go to Section B) or NO

3. _____ I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months. YES (If yes, go to*) or NO

4. _____ I have had problems with my eyes, ears. Or nasal passages/ sinuses. YES (If yes, go to Section C) or NO

5. _____ I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. YES (If yes, go to*) or NO

6. _____ I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. YES (If yes, go to Section D) or NO

7. _____ I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. YES (If yes, go to Section E) or NO

8. _____ I have had back problems, hernia, ulcers, or diabetes. YES (If yes, go to Section F) or NO

9. _____ I have had stomach or intestine problems, including recent diarrhea. YES (If yes, go to Section G) or NO

10. _____ I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam). YES (If yes, go to*) or NO

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions in sections A through G, please read and agree to the statement above by signing and dating it AND download the RSTC Diver Medical form and take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

Section A – I have/ have had:

_____ Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease. YES* or NO

_____ Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limit my physical activity/exercise. YES* or NO

_____ A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. YES* or NO

_____ Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema, YES* or NO

_____ Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. YES* or NO

Section B – I am over 45 years of age AND:

_____ I currently smoke or inhale nicotine by other means. YES* or NO

_____ I have a high cholesterol level. YES* or NO

_____ I have high blood pressure. YES* or NO

_____ I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, or have a family history of heart disease before age 50 (including abnormal heart rhythm, coronary artery disease or cardiomyopathy). YES* or NO

Section C – I have/ have had:

_____ Sinus surgery within the last 6 months. YES* or NO

_____ Ear disease or ear surgery, hearing loss, or problems with balance. YES* or NO

_____ Recurrent Sinusitis within the past 12 months. YES* or NO

_____ Eye Surgery within the past 3 months. YES* or NO

Section D – I have/ have had:

_____ Head injury with loss of consciousness within the past 5 years YES* or NO

_____ Persistent neurologic injury or disease. YES* or NO

_____ Recurring migraine headaches within the past 12 months, or take medications to prevent them. YES* or NO

_____ Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. YES* or NO

_____ Epilepsy, seizures, or convulsions, OR take medications to prevent them. YES* or NO

Section E – I have/ have had:

_____ Behavioral health, mental or psychological problems requiring medical/ psychiatric treatment. YES* or NO

_____ Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. YES* or NO

_____ Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care. YES* or NO

_____ An addiction to drugs or alcohol requiring treatment within the last 5 years. YES* or NO

Section F – I have/ have had:

_____ Recurrent back problems in the last 6 months that limit my everyday activity. YES* or NO

_____ Back or spinal surgery within the last 12 months. YES* or NO

_____ Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months. YES* or NO

_____ An uncorrected hernia that limits my physical abilities. YES* or NO

_____ Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. YES* or NO

Section G – I have had:

_____ Ostomy surgery and do not have medical clearance to swim or engage in physical activity. YES* or NO

_____ Dehydration requiring medical intervention within the last 7 days. YES* or NO

_____ Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. YES* or NO

_____ Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). YES* or NO

_____ Active or uncontrolled ulcerative colitis or Crohn’s disease. YES* or NO

______ Bariatric surgery within the last 12 months. YES* or NO

* If you answered YES to any of the questions in sections A through G, please read and agree to the statement below by signing and dating it AND download the RSTC Diver Medical form and take it (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.