Medical Assessment Form For Fitness To Dive Page 5
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6Medical Assessment
Form No.:
CFT/IUC409
Sport Diving
Issue No.:
4.2
Dated:
01-Sep-2017
Irish Underwater Council
DOCTORS STATEMENT OF HEALTH FOR SPORT DIVING
This is to certify that I have today reviewed the diver’s self-declaration, interviewed, and
examined:
Name
Address
Date of birth: Day
Month
Year
Initial those statements that do, and delete (cross out) those that do not apply:
I have assessed the candidate in accordance with UKDMC Standards.
I can find no conditions which are incompatible with compressed gas and / or
breath-hold diving.
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Signature of Medical Examiner
Name of Medical Examiner
Date
Medical Examiner Stamp
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Signature of Diver
Name of Diver
Date
Page 5 of 6
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