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Diving Center Cap de Creus Dive — El Port de la Selva

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Participant questionnaire (confidential)

Diving requires good physical and mental health. There are some medical conditions that can be dangerous during diving, and they are listed below. Those who have or are predisposed to any of these conditions should be evaluated by a doctor. This Diver's Medical Questionnaire provides a basis for determining whether you should seek this evaluation. If you have any concerns about your physical condition for diving and it is not represented in this form, consult your doctor before diving. References to "diving" in this form encompass both recreational diving with autonomous equipment and freediving. This form is primarily designed as an initial medical examination for new divers, but it is also appropriate for divers undergoing continuing education. For your safety and that of others who may dive with you, please answer all questions honestly.

    Instructions

    Complete this questionnaire as a prerequisite for freediving training or diving with autonomous equipment. For women: If you are pregnant or trying to become pregnant, do not dive.

    1. Have I had problems with my lungs/respiration, heart, or blood?

    2. Am I over 45 years old?

    3. Is it difficult for me to perform moderate exercise (for example, walking 1.6 kilometers/one mile in 12 minutes or swimming 200 meters/yards without resting), or have I been unable to engage in normal physical activity due to reasons of physical or health status in the last 12 months?

    4. Have I had problems with my eyes, ears, or nasal/sinus passages?

    5. Have I had surgery in the last 12 months or do I have ongoing issues related to a previous surgery?

    6. Have I lost consciousness, had migraines, seizures, stroke, significant head injury, or suffered from persistent neurological injury or illness?

    7. Have I had psychological problems (or received psychological treatment in the last 5 years), been diagnosed with a learning disability, personality disorder, panic attacks, or addiction to drugs or alcohol?

    8. Have I had problems with the back, hernia, ulcers, or diabetes?

    9. Have I had stomach or intestinal problems, including recent diarrhea?

    10. Am I taking prescribed medications (with the exception of contraceptives or antimalarial drugs other than Lariam-mefloquine)?

    Participant's Signature

    Please read and accept the participant's declaration below with your signature.

    Participant's Declaration: I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for not disclosing any existing or past health condition.


    PARTICIPANT'S SIGNATURE

    DATE OF BIRTH (dd/mm/yy)

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