Medical Declaration

MEDICAL DECLARATION

Please read carefully before signing

This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your

signature on this statement is required for you to participate in the scuba training programme offered.

Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enrol in the scuba-training

program. If you are a minor, you must have this Statement signed by a parent or guardian.

Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not

followed, however, there are increased risks.

To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory

systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical

problem, or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking

medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion.

You will also need to learn from the instructor the important safety rules regarding breathing and equalisation while scuba diving. Improper use of scuba equipment can

result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.

If you have any additional questions regarding this Medical Statement or the Medical History section, review them with your instructor before signing. In some cases, a

diving medical is mandatory

MEDICAL HISTORY

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 pre-existing 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, you must ask LPDIVING for a PADI Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to your physician. If

your GP cannot assist, LPDIVING can recommend Dr David Adey of Woolston, Southampton on 023 8042 0467 (except in cases where your medical history is

involved, as this will not be known to him). This must be presented to LPdiving before you commence your training.

Could you be pregnant or are you attempting to become pregnant?

Dysentery or dehydration requiring medical intervention?

Are you presently taking prescription medications? (with the exception of

Any dive accidents or decompression sickness?

birth control or anti-malarial)

Are you over 45 years of age and can answer YES to one or more of the

Inability to perform moderate exercise (example: walk

1.6km/one mile within 12 minutes)?

following?

•

Head injury with loss of consciousness in the past five

currently smoke a pipe, cigars, or cigarettes?

years?

•

Recurrent back problems?

have a high cholesterol level?

•

Back or spinal surgery?

have a family history of heart attack or stroke?

•

Diabetes?

are currently receiving medical care?

•

Back, arm or leg problems following surgery, injury or

high blood pressure?

fracture?

•

High blood pressure or take medicine to control blood

Diabetes mellitus, even if controlled by diet alone?

pressure?

Have you ever had or do you currently have …

Heart disease?

Asthma, or wheezing with breathing, or wheezing with exercise?

Heart attack?

Frequent or severe attacks of hayfever or allergy?

Angina, heart surgery or blood vessel surgery?

Frequent colds, sinusitis or bronchitis?

Sinus surgery?

Any form of lung disease?

Ear disease or surgery, hearing loss or problems with

balance?

Pneumothorax (collapsed lung)?

Recurrent ear problems?

Other chest disease or chest surgery?

Bleeding or other blood disorders?

Behavioural health, mental or psychological problems (Panic attack, fear

Hernia?

of closed or open spaces)?

Epilepsy, seizures, convulsions or take medications to prevent them?

Ulcers or ulcer surgery?

Recurring complicated migraine headaches or take medications to prevent

A colostomy or ileostomy?

them?

Blackouts or fainting (full/partial loss of consciousness)?

Recreational drug use or treatment for, or alcoholism in the

past five years?

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.

Name ___________________________________________________

Signature ________________________________________________

_________________________________________________________

Date ____________________________________________________

Signature of adult with parental responsibility (if student is under 18)

IMPORTANT NOTICE: If you are learning to dive for purposes other than leisure, ie, as part of your job, and/or your employer is paying for you to learn as part of your

job please tick box A. You may require a full HSE medical. If your course is strictly for leisure purposes then please tick box B

A

B

IF YOU ANSWER YES TO ANY OF THE ABOVE YOU MUST

HAVE A MEDICAL BEFORE STARTING THE COURSE