Date of birth

Today's date

1 - I have had problems with my lungs, breathing, heart and/or blood that affect my normal physical or mental performance.
YESNO
[group gruppregunta1] [group gruppregunta1
BOX A - I HAVE/HAD:

Thoracic surgery, cardiac surgery, heart valve surgery, stenting or pneumothorax (collapsed lung).
YESNO

Asthma, wheezing, severe allergies, hay fever or congested airways in the last 12 months that limit my physical activity/
exercise.
YESNO

Recurrent bronchitis and persistent cough in the last 12 months, OR have been diagnosed with emphysema.
YESNO

A diagnosis of COVID-19
YESNO

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2 - I am over 45 years old
YESNO
[group gruppregunta2] [group gruppregunta2
BOX B - I AM OVER 45 YEARS OLD AND:

I currently smoke or inhale nicotine by other means.
YESNO

I have a high cholesterol level
YESNO

I have high blood pressure.
YESNO

I have had a family member (1st OR 2nd degree of consanguinity) who died of sudden death, heart disease or stroke.
before age 50, OR I have a family history of heart disease before age 50 (including abnormal heart rhythms),
coronary artery disease or cardiomyopathy)
YESNO

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3-I find it difficult to do moderate exercise (e.g., walking 1.6 kilometres/one mile in 12 minutes or swimming 200 metres/yards without rest),
O I have not been able to participate in normal physical activity due to fitness or health reasons in the last 12 months.
YESNO
4-I have had problems with my eyes, ears, or nostrils/sinuses.
YESNO
[group Gruppregunta3] [group Gruppregunta3

Sinus surgery in the last 6 months
YESNO

Diseases of the ear or ear surgery, hearing loss or impaired balance.
YESNO

Recurrent sinusitis in the last 12 months
YESNO

Eye surgery in the last 3 months
YESNO

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5-I have had surgery in the last 12 months, OR I have ongoing problems related to a previous surgery.
YESNO
6-I have lost consciousness, had migraine headaches, seizures, stroke, significant injury, etc.
in the head, or have suffered from persistent neurological injury or disease.
YESNO
[group Gruppregunta4] [group Gruppregunta4
BOX D - I HAVE/HAD:

Head injury with loss of consciousness within the last 5 years.
YESNO

Persistent neurological injuries or diseases.
YESNO

Recurrent migraine headaches in the last 12 months, or I take medication to prevent them.
YESNO

Fainting or blackouts (total/partial loss of consciousness) within the last 5 years.
YESNO

Epilepsy, seizures or convulsions, OR I take medication to prevent them.
YESNO

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7-I have had psychological problems (or have received psychological treatment in the last 5 years), I was diagnosed with a disability
learning disabilities, personality disorder, panic attacks or an addiction to drugs or alcohol.
YESNO
[group groupquestion5] [group groupquestion5
BOX E - HAVE/HAD:

Behavioural health, mental or psychological problems requiring medical/psychiatric treatment.
YESNO

Major depression, suicidal tendencies, panic attacks, uncontrolled bipolar disorder requiring psychiatric medication/treatment.
YESNO

I have been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
YESNO

A drug or alcohol addiction requiring treatment within the last 5 years.
YESNO

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8-I have had back problems, hernia, ulcers or diabetes.
YESNO
[group groupquestion6]
BOX F - HAVE/HAD:

Recurrent back problems in the last 6 months limiting my daily activity.
YESNO

Back or spinal surgery in the last 12 months
YESNO

Diabetes, either insulin-controlled or diet-controlled, OR gestational diabetes within the last 12 months.
YESNO

An uncorrected hernia that limits my physical abilities.
YESNO

Active or untreated ulcers, problematic wounds or ulcer surgery within the last 6 months.
YESNO

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9-I have had stomach or intestinal problems, including recent diarrhoea.
YESNO
[group groupquestion7]
BOX G - I HAVE:

I have ostomy surgery and am not medically cleared to swim or participate in physical activity.
YESNO

Dehydration requiring medical intervention in the last 7 days.
YESNO

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
YESNO

Frequent heartburn, regurgitation or gastro-oesophageal reflux disease (GORD).
YESNO

Active or uncontrolled ulcerative colitis or Crohn's disease.
YESNO

Bariatric surgery in the last 12 months.
YESNO

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If NO to the 10 questions above, a medical evaluation is not required. Please read and accept the statement from the
participant below with date and signature.
Participant's DeclarationI 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 my failure to disclose any existing or past health conditions.

If you answered YES to questions 3, 5 or 10 above O to any of the questions on page 2, read and agree to the statement
the above dated and signed AND bring the completed Doctor's assessment (consult the dive centre) to your physician for a medical evaluation. Participation in a dive training programme requires the approval of your physician.