SECTION B SUGGESTED SCOPE OF A MEDICAL QUESTIONNAIRE FOR SCREENING CANDIDATES FOR RECREATIONAL SCUBA DIVING
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1 SECTION B SUGGESTED SCOPE OF A MEDICAL QUESTIONNAIRE FOR SCREENING CANDIDATES FOR RECREATIONAL SCUBA DIVING HEALTH STATEMENT FOR PERSONS WISHING TO UNDERTAKE SCUBA- DIVING TRAINING The provision of inaccurate, incomplete or misleading information, or withholding any information is likely to place you at risk and renders any subsequent medical opinion unreliable. Introduction This is a medical questionnaire designed to identify any health issues that may increase the risk to you from undertaking SCUBA diving. In order to undertake dive training you will be required to sign this form on the understanding that relevant medical details may be passed to your dive trainer. You will also be informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training programme. Your signature on this statement is required for you to participate in the scuba training program offered. If you are under 18 years of age, you must have this questionnaire signed by a parent or guardian. Training to be offered by and (Instructors) located at (Facility) Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your lungs, heart and circulation must be in good health. All body air spaces such as the sinuses and middle ears must be normal and healthy. A person with heart disease, a current head cold or lung congestion, epilepsy (fits), any severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should inform the doctor and the instructor before participating in this programme. You will also learn from the instructor the important safety rules regarding breathing and ear clearing while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely. If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing. Candidate initials 11
2 Please read carefully before signing. 1. Surname Other Names 2. Date of Birth (dd/mm/yyyy) 3. Address State: Postcode 4. Sex Male / Female 5. Telephone (Home) 6. Principal Occupation 7. Telephone (Work) 8. (Optional) 9. Are you regularly taking any prescription tablets, medicines or drugs? List: 10. Have you had any reactions to drugs or medicines or foods? Details: Please answer the following questions on your past or present medical history (from question 11 onwards) with a YES or NO. If you are not sure, answer YES. Have you ever had or do you now have any of the following? Tick Yes or No 11. Any continuing eye or visual problems (apart from needing glasses or contact lenses)? 12. Sinusitis (e.g. hay fever, sinus infections)? 13. Any other nose or throat problem (apart from previous coughs and colds)? 14. Dentures or plates that are removable? YES NO Physician s comments 15. Deafness or ringing noises in ear(s)? 12
3 16. Discharging ears or other infections? 17. Previous ear operation (including as a child)? 18. Giddiness or loss of balance? YES NO Physician s comments 19. Severe motion sickness? 20. Any ear problems or severe headaches when flying in aircraft? 21. Severe or frequent headaches, including migraine? 22. Faints or blackouts? 23. Convulsions, fits or epilepsy? 24. Any episodes of unconsciousness? 25. Depression requiring medical treatment? 26. Claustrophobia? 27. Mental illness? 28. Heart disease? 29. Awareness of a racing or irregular heart beat? 30. High blood pressure? 31. Rheumatic fever? 32. Discomfort in your chest with exertion? 33. Very short of breath on exertion (out of proportion to the exercise)? 34. Bronchitis or pneumonia? 35. Pleurisy or severe chest pain? 36. Coughing up phlegm or blood? 37. Chronic or persistent cough? 38. Tuberculosis ( TB )? 39. Pneumothorax ( collapsed lung )? 40. Frequent chest colds? 41. Asthma or wheezing? 42. Use a puffer (medication inhaler for asthma)? 43. Any other chest complaint? 44. Operation on chest, lungs, or heart? 45. Peptic ulcer or acid reflux requiring treatment? 46. Vomiting blood or passing red or black motions? 47. Jaundice, hepatitis or liver disease? 48. Malaria? 13
4 49. Severe loss of weight? 50. Hernia or rupture? 51. Major joint or back injury? 52. Paralysis, muscle weakness or numbness? 53. Kidney disease? 54. Diabetes? 55. Blood disease or bleeding problem? 56. Could you be pregnant, or are you trying to become pregnant? 57. Have you ever had a diving accident or decompression illness/sickness? Water skills Previous Diving Experience? When, and how many dives? Details: Previous qualifications (if any): Can you swim? Have you ever had any problem during or after swimming or diving? Details: Do you snorkel dive regularly? Candidate Statement I certify that the above information is true and complete to the best of my knowledge. I hereby authorise (dive training organisation) to pass this information to a diving doctor of my choosing. I also authorise that doctor to obtain or supply medical information regarding me to other doctors as may be necessary for medical purposes in my personal interest. Signed: Date: Note Any chronic disease, such as hepatitis A, B, C, AIDS or tuberculosis, may increase your risks from diving. If you have a chronic disease please discuss it with the doctor who will then be able to advise you whether you will be at increased risk. 14
5 SPUMS PRE-DIVE MEDICAL FORM FOR ENTRY-LEVEL SCUBA DIVERS Append the diver medical statement above Notes or additions to medical history: MEDICAL EXAMINATION: To be completed by an Approved Medical Practitioner 1. Height cm 2. Weight kg 3.Visual acuity R 6/ Corrected 6/ L 6/ Corrected 6/ 4. Blood Pressure 5. Pulse rate bpm 6. Urinalysis Albumin Glucose 7. Respiratory function tests including: (attach results) FVC FEV 1 mmhg 8. CXR (if required) Date: Place: Result: 9. Audiometry db Right Ratio (%) (Hz) Left 10. ECG (if indicated) Clinical Examination/Assessment Normal Abnormal Notes on any abnormalities 11. Nose, septum, airway 12. Mouth, throat, teeth, bite 13. External auditory canal 14. Tympanic membrane 15. Middle ear autoinflation 16. Neurological Eye movements Pupillary reflexes Limb reflexes Finger-nose Sharpened Romberg s 17. Abdomen 18. Chest auscultation 19. Cardiac auscultation 20. Other abnormalities 15
6 STATEMENT OF HEALTH FOR RECREATIONAL DIVING This Section to be completed by a Medical Practitioner with appropriate training in diving medicine This is to certify that I have today interviewed and examined: Name... Address Date of birth.../.../... Initial the statements that apply: I have assessed the candidate in accordance with the SPUMS Recreational Dive Medical. I can find no conditions which are incompatible with compressed gas, scuba and surface supplied breathing apparatus (SSBA) and / or breath-hold diving. I have explained the health risks of diving disclosed by this examination to the candidate and we have discussed how these risks may be reduced. The candidate appears to have a good understanding of these risks. Based upon my assessment, the candidate should not dive with compressed gases (scuba and SSBA). Based upon my assessment, the candidate should not breath-hold dive. Advice: (append further notes as required) Condition 1: Condition 2:....../.../... (Signature of Medical Practitioner) (Date) (Name, address and telephone number of the Medical Practitioner) This Section to be completed by the Candidate Initial the statements that apply:... I understand the health risks that I may encounter in diving and how these risks may be reduced.... I also understand that the medical practitioner s recommendation herewith is based, in part, upon the disclosure of my medical history.... I agree to accept any responsibility and liability for health risks associated with my participation in underwater diving, including those that are due to or are influenced by a change in my health and / or my failure to disclose any existing or past health condition to the medical practitioner.... I hereby authorise the medical practitioner to supply information with regard to my medical fitness to dive to the diving instructor /.../... Signature of candidate Name of Candidate Date 17
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Greetings from Oklahoma Wesleyan University Student Health Services! STUDENT HEALTH OFFICE AND MEDICAL ATTENTION MEDICAL FORMS PHYSICAL EXAMS
Return all medical forms to: Student Health Department Oklahoma Wesleyan University 2201 Silver Lake Road Bartlesville, OK 74006 Greetings from Oklahoma Wesleyan University Student Health Services! My
READ THIS LEAFLET VERY CAREFULLY, AND KEEP IT IN A SAFE PLACE. FLU IS SPREADING IN IRELAND, AND THIS INFORMATION IS IMPORTANT FOR YOU AND YOUR FAMILY.
READ THIS LEAFLET VERY CAREFULLY, AND KEEP IT IN A SAFE PLACE. FLU IS SPREADING IN IRELAND, AND THIS INFORMATION IS IMPORTANT FOR YOU AND YOUR FAMILY. Information and medical advice for the public on Pandemic
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
Physician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
How To Get A Life Insurance Policy From Aia Australia
Personal Statement/ Member s Declaration Group Life including Salary Continuance Issued March 2004 Member ID: Employer Name: Disclosure Notice Your duty of disclosure Before you enter into a contract of
PATIENT REGISTRATION. First Name: Middle Initial: Last Name: Home Phone: Work Phone:
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address City, State, Zip: Home Phone: Work Phone: Cell Phone: Birth Date: Age: Sex: Male Female Soc. Sec. #: Occupation: Employer: Marital Status:
Application for Employment
POSITION SOUGHT Application for Employment Please complete both the front and back of this form (if you have already submitted your resume or are enclosing you do not need to complete the section on page
OrthoVirginia Registration Information 2016
OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
Health questionnaire for the insured TAF life insurances
You are applying for life insurance. With your application goes a declaration of your health. You can fill out your declaration in this health questionnaire. When your application comprises of two insured