MEDICAL HISTORY
The objective of
this questionaire is to determine if you should be
examined by your doctor before taking part in activities
related to recreational dive training.
Affirmative answering not necesarilly disqualifies you
for diving.
SI NO CUESTIONARIO
Could you be pregnant or are you attemping to become
pregnant?
Do you regularly take prescription or nonprescription
medications?
Are you over 45 years of age and have one or more of the
following?
• currently smoke a pipe, cigars, or cigarettes
•
have a high cholesterol level
• have a family history of heart attacks or strokes.
SI NO ¿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?
Claustrophobia
or agoraphobia (fear of closed or opened spaces)?
Epilepsy, seizures, convulsions or take medications to
prevent them?
Do you frequently
suffer from motion sickness (seasick, carsick, etc.)?
History of
recurrent back problems or back surgery?
History of
diabetes?
History of high
blood pressure or take medicine to control blood
pressure?
History of any
heart disease or heart attacks?
Angina or heart or
vessel surgery?
History of ear or
sinus surgery?
History of ear
disease, hearing loss or problems with balance?
History of bleeding
or other blood disorders?
History of any tipe
of hernia?
History of
colostomy?
