| Participant: Course: |
| 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 program offered
by ______________________________(instructor) and
Huron Scuba, Snorkel and Adventure Travel Inc.. located in the
city of Ann Arbor, state/province of Michigan.
Read this statement prior to signing it. You must complete this
Medical Statement, which includes the medical questionnaire section, to
enroll 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
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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 learn from the instructor the
important safety rules regarding breathing and equalization 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 Questionnaire section, review them with your
instructor before signing.
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| To the Participant: |
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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.
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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.
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| ____ | 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 |
| Have you ever had or do you currently have... |
| ____ | Asthma, or wheezing with breathing, or wheezing with exercise? |
| ____ | Frequent or severe attacks of hayfever 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)? |
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| ____ | Frequent or severe suffering from motion sickness (seasick, carsick, etc.)? |
| ____ | 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? |
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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.
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| _______________________________________ |
_________________ |
_______________________________________ |
_________________ |
| Signature |
Date |
Signature of Parent or Guardian |
Date |
| PRODUCT No. 10063 (Rev. 06/07) Ver. 2.01 |
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| Please print legibly. |
| Name ________________________________________ |
Birth Date ________________ |
Age __________ |
| First Initial Last |
Day/Month/Year |
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| Mailing Address ______________________________________________________________________ |
| City ______________________________ |
State/Province/Region ____________________ |
| Country _________________________________________ |
Zip/Postal Code ____________________ |
| Home Phone (_______) ______________________________ |
Business Phone (______) ____________________ |
| Fax (______) ____________________ |
Email ________________________________________ |
| Name and address of your family physician |
| Physician _________________________________________ |
Clinic/Hospital _________________________________________ |
| Address __________________________________________________________________________________ |
| Date of last physical examination _________________________________________ |
| Name of examiner _________________________________________ |
Clinic/Hospital _________________________________________ |
| Address __________________________________________________________________________________ |
| Phone (______) ____________________ |
Email _________________________________________ |
| Were you ever required to have a physical for diving? [ ] Yes [ ] No |
If so, when? _________________________________________ |
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This person applying for training or is presently certified to engage in scuba (self-contained underwater breathing apparatus) diving. Your opinion of
the applicant's medical fitness for scuba diving is requested. There are guidelines attached for your information and reference.
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| Physician's Impression |
| [ ] I find no medical conditions that I consider incompatible with diving. |
| [ ] I am unable to recommend this individual for diving. |
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| Remarks _________________________________________________________________________________________________________________ |
| _________________________________________________________________________________________________________________ |
| _________________________________________________________________________________________________________________ |
| _______________________________________________________________ |
Date _________________________________________ |
| Physician's Signature or Legal Representative of Medical Practitioner |
Day/Month/Year |
| Physician _________________________________________ |
Clinic/Hospital _________________________________ |
| Address __________________________________________________________________________________ |
| Phone ( ) ____________________ |
Email _________________________________________ |
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