Medical Assessment Form For Fitness To Dive
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6Medical Assessment
Form No.:
CFT/IUC409
Sport Diving
Issue No.:
4.2
Dated:
01-Sep-2017
Irish Underwater Council
SECTION A: TO BE COMPLETED BY THE CANDIDATE:
DIVER STATEMENT OF HEALTH FOR SPORT DIVING
Note: FAILURE TO DISCLOSE A MEDICAL CONDITION MAY INVALIDATE YOUR INSURANCE
Surname
Other
Date of birth
Names
Address
Tel No.
Sex Male
Female
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
How many units per week?
Are you taking any tablets or medicines or drugs?
Yes
No
List:
Do you have any
Yes
No
allergies? Details:
Have you ever had any reactions to medicines or
Yes
No
foods? Details:
HAVE YOU EVER HAD OR DO YOU NOW HAVE ANY OF THE FOLLOWING?
Tick Yes or No as appropriate
Notes on history
YES
NO
Previous diving medical
Prescription glasses
Hay fever
Sinusitis
Other nose or throat problem
Recent dental procedures
Deafness or ringing tones in ear(s)
Discharging ears or other infections
Operation on ears
Giddiness or loss of balance
Severe motion sickness
Problems when flying in aircraft
Severe or frequent headaches
Migraine
Fainting or blackouts
Convulsions, fits or epilepsy
Unconsciousness
Concussion or head injury
Sleep walking
Severe depression
Claustrophobia
Mental illness
Abnormal blood test
ECG (Heart tracing)
High blood pressure
Rheumatic fever
Discomfort in your chest with exertion
Short of breath on exertion
Bronchitis or pneumonia
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