RSTC Medical Form

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 pre existing condition that may affect your safety while diving and you must seek the advice of your physician.

Please answer the following questions on your past or present medical history with a check mark. If you are not sure, check it. If any of these items apply to you, you must have written approval from a physician prior to participating in scuba diving training.

Could you be pregnant or are you attempting to become pregnant? Do you regularly take prescription or non prescription medications other than birth control 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 Have you ever had or do you currently have ... Asthma or wheezing with breathing, or wheezing with exercise? Frequent or severe attacks of hayfeaver or allergies? Frequent colds, sinusitis or bronchitis? Any form of lung disease? Pneumothorax (collapsed lung)? History of chest surgery? Claustrophobia or agoraphobia ( fear of closed or open spaces)? Behavioral health problems? Epilepsy, seizures, convulsions or take medications to prevent them? Recurring migraine headaches or take medications to prevent them? History of blackouts or fainting (full/partial loss of consciousness)? Do you frequently suffer from motion sickness (seasick, carsick,etc.)? History of diving accidents or decompression sickness? History of recurrent back problems? History of back surgery? History of diabetes? History of back, arm, or leg problems following surgery, injury, or fracture? Inability to perform moderate exercise (example walk one mile in 12 minutes)? History of high blood pressure or take medicine to control blood pressure? History of any heart disease? History of heart attacks? Angina or heart surgery or blood vessel surgery? History of ear or sinus surgery? History of ear disease, hearing loss or problems of balance? History of problems equalizing (popping) ears with airplane travel? History of bleeding or other blood disorders? History of any type of hernia? History of ulcers or ulcer surgery? History of colostomy? History drug or alcohol abuse?

Student Information
Name	Birth Date	Age
Mailing Address Line 1
Mailing Address Line 2
City	State	Zip
E-mail
Home Phone	Business Phone

Signature of Student and Date

Signature of Parent or Guardian
(where applicable)

Physician Information (Only required if any questions checked in the Medical History Form.)
Physician	Clinic/Hospital
Mailing Address Line 1
Mailing Address Line 2
City	State	Zip
Business Phone	Business Fax

Physicians Impression

I find no medical conditions that I consider incompatible with diving.
I am unable to recommend this individual for diving.

Remarks ______________________________________________________

Physicians Signature _____________________________ Date ____________