Please answer the following questions on your past or present medical history with a YES or NO. 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.
_____ 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 hear tattack 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 pre- vent them?
_____ Blackouts or fainting (full/partial loss of consciousness)?
_____ 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?
_____ 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?
_____ Ulcers or ulcer surgery ?
_____ A colostomy or ileostomy?
_____ Recreational drug use or treatment for, or alcoholism in the past five years?