Establishing secure connection…Loading editor…Preparing document…

Healthcare Diver Medical Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE DIVER MEDICAL FORM

Instructions: Complete this form truthfully and to the best of your knowledge. Information contained herein will be used to evaluate medical fitness to dive and to determine whether referral for further medical examination is required. Failure to disclose relevant medical history may increase risk during diving activities and may invalidate medical clearances.

Patient Information

Date of birth:

Gender:

Phone:

Email:

Emergency Contact

Relationship:

Phone:

Insurance and Certification

Policy number:

Group number:

Subscriber name:

Agency:

Cert number:

Date of last dive:

Medical History (Check all that apply)

Use the checkboxes to indicate prior or current medical conditions and provide details where indicated. Certain conditions are considered contraindications to diving and require physician evaluation.

















Screening Questions (Check yes if applicable)

Please check Yes for any question that applies and provide details in the field below. A Yes answer may require physician review prior to diving certification or activity.







Consent, Authorization, and Certifications

I certify that the above statements are complete and accurate to the best of my knowledge. I understand that withholding or misrepresenting relevant medical information may place me at increased risk during diving activities and may invalidate any clearance or insurance coverage. I authorize the release of medical information necessary to determine my fitness to participate in diving activities.

Determination of fitness to dive is a medical decision to be made by a licensed physician. This form documents relevant history and authorizations for evaluation. If indicated, you may be referred for further testing (e.g., pulmonary function testing, cardiac testing, specialist evaluation) prior to clearance.

Patient Name:

Signature:

Date:

If signed by a parent or legal guardian: Relationship to patient:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Healthcare Diver Medical Form Is and Who It Serves

The Healthcare Diver Medical Form documents a diver's medical fitness, health history, and physician clearance for professional or commercial diving activities. It records vital clinical findings—vision, hearing, cardiovascular and pulmonary assessments, neurological screening, medication review, and any dive-specific conditions such as decompression illness history—so employers, medical review officers, and dive supervisors can determine fitness for duty. The form is used by clinics, occupational health providers, contractors, and regulatory programs to meet safety and contractual requirements while capturing patient consent for release of relevant health information.

Why this form matters for safety and compliance

A completed Healthcare Diver Medical Form provides a standardized medical record that supports safe dive operations, documents physician clearance, and helps satisfy employer and insurer requirements while reducing operational risk.

Why this form matters for safety and compliance

Which people and organizations typically complete this form

The Healthcare Diver Medical Form is completed by clinical staff and the diver, then reviewed and signed by an authorized physician.

  • Commercial divers and offshore personnel who need medical clearance to work in pressurized or hazardous underwater environments.
  • Occupational health clinics and dive medical officers responsible for examinations, documentation, and fitness determinations.
  • Employers, safety managers, and insurers who require proof of medical fitness before deployment on dive assignments.

Accurate completion reduces delays, protects worker safety, and creates an auditable clinical record for future reviews.

Primary signer roles and responsibilities

Diver / Patient

The diver must provide complete medical history, disclose current medications, and report past dive-related incidents. Their attestations and signature confirm accuracy and consent to necessary evaluations and information release.

Examining Physician

A licensed clinician documents the physical exam, records findings, states fitness for diving (fit, fit with restrictions, or unfit), and signs and dates the form to create an authorized medical determination.

Essential data elements captured on the form

Personal Identifiers: Name, DOB, employer, and contact
Medical History: Past diagnoses, surgeries, dive incidents
Medications: Current prescriptions and OTC drugs
Physical Exam: Cardio, pulmonary, neurological checks
Physician Clearance: Fitness status and restrictions
Consent and Release: Patient signature for information sharing

Key risks of incomplete or inaccurate forms

Operational Risk: Increased chance of dive incident
Liability Exposure: Employer and physician legal risk
Insurance Denial: Claims may be refused for missing records
Regulatory Noncompliance: Violations of contract or safety rules
Invalid Clearance: Unclear or unsigned physician determinations
Data Privacy Breach: Improper handling of PHI under HIPAA

Common preparation and processing challenges

  • Incomplete medication lists or omitted pre-existing conditions that change fitness determinations and delay clearance.
  • Missing physician signature or date that renders the clearance invalid for employer onboarding and insurance processes.
  • Unsecured transfer of PHI via email or storage without a business associate agreement, creating HIPAA exposure.
  • Late submissions that postpone assignments and increase operational downtime and cost for contractors.

Step-by-step: completing the Healthcare Diver Medical Form

Follow these steps to collect, verify, and finalize medical clearance before dive assignments.

  • 01
    Gather ID: Confirm full legal name and date of birth.
  • 02
    Record History: Enter past illnesses, surgeries, and dive incidents.
  • 03
    Perform Exam: Document cardiovascular, pulmonary, and neuro checks.
  • 04
    Physician Sign-off: Physician signs, dates, and states fitness.

Configuring an online workflow for the form

Set up fields and routing to ensure consistent collection, clinical review, and secure storage.

Field Configuration
Patient Info Fields Required; verify with ID
Physician Attestation Required signature field
Attachment Support labs or imaging PDFs
Routing Send to physician then employer

Typical document flow for clinic to employer

A straightforward routing sequence reduces processing time and preserves an auditable trail for clinical and administrative reviewers.

  • Upload: Clinic uploads completed form
  • Physician Review: Doctor verifies exam and signs
  • Employer Receipt: Employer receives signed copy
  • Archive: Store with retention controls

Typical sections included in a professional diver medical form

A well-structured form separates identity, history, clinical findings, physician judgment, and administrative controls to support clear decisions and defensible records.

Identification

Full legal name, date of birth, employer details, and emergency contact information to reliably match the medical record with the diver and assignment.

Medical History

Detailed prompts for prior illnesses, surgeries, medications, allergies, and previous dive-related injuries or decompression events to identify risk factors.

Physical Examination

Structured fields for cardiovascular, respiratory, ENT, neurological, and musculoskeletal findings with space for vital signs and test results.

Diagnostic Attachments

Area to upload ECGs, chest x-rays, pulmonary function tests, and other supporting documents that inform the fitness determination.

Physician Determination

A concise conclusion (fit, fit with restrictions, unfit) with the clinician's signature, license number, and date to create an authoritative medical decision.

Consent and Release

Patient signature block authorizing release of medical information to employer, insurer, or designated safety officers consistent with HIPAA rules.

Practical tips for accurate and efficient completion

Adopt consistent data entry, secure handling, and verification steps to protect health data and minimize return-to-sender cycles.

Use consistent identifiers across records
Record full legal names and birthdates exactly as on government ID to avoid mismatches between medical records and employer files.
Capture supporting test results at time of exam
Attach ECG, pulmonary testing, or imaging to prevent later disputes and expedite fitness determinations.
Limit PHI distribution
Share only necessary health information with employers and insurers; document patient consent as required by HIPAA.
Standardize physician language
Use clear fitness categories and list any restrictions to prevent operational misunderstandings and ensure enforceability.

Recommended timing for submission and review

Timely review prevents deployment delays; adopt a cutoff before assignments to allow physician evaluation and follow-up testing.

Pre-deployment window:

Submit at least 7 days before scheduled dive

Physician review time:

Allow 24–72 hours for clinical review

Follow-up testing:

Complete within 7–14 days if ordered

Re-evaluation interval:

Annual or sooner after medical event

Record update:

Update whenever health status changes

How eSignature vendors compare for secure clinical forms

Select an eSignature provider that supports HIPAA, audit trails, and appropriate pricing for your deployment; signNow is listed first for parity in features and cost comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year No cap No cap No cap

Technical considerations for secure eSubmission

Ensure the platform supports required integrations, document types, and security controls before eSubmission.

  • Integrations: Salesforce, NetSuite, MS 365
  • Formats: PDF, DOCX, HTML, Excel
  • Security: TLS 1.2/1.3 and AES-256

Real-world examples of digital medical forms in use

Healthcare and field services use digital medical forms to speed approvals and maintain secure records.

Fertility Centers of Illinois

Clinical teams moved to online forms to streamline patient workflows and reduce turnaround.

  • Real-world integration with practice operations improved record availability.
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Martin Properties

An operations team digitized health-clearance forms to avoid in-person delays.

  • Faster document exchange reduced assignment downtime.
  • "I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently."

Frequently asked questions about the Healthcare Diver Medical Form

Answers to common questions on legal validity, PHI handling, digital signatures, notarization, and changing a completed form.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.