Healthcare Diver Medical Questionnaire

Healthcare Diver Medical Questionnaire

Purpose: This form gathers medical information to determine fitness to participate in diving activities. All questions must be answered truthfully. A positive response to any question may require further evaluation by a licensed physician with diving medicine experience prior to certification for diving activities. Information provided will be maintained confidentially and released only as necessary for medical care, safety, or as authorized below.

Diver / Patient Information

Date of Birth:    Gender:

Emergency Contact

Diving Experience

Certification Agency/Level:    Years Diving:

Date of last dive:    Maximum depth recently reached (feet/meters):

Insurance Information

Medical History — Please check all that apply

Heart disease, heart attack, angina, or coronary artery disease
High blood pressure or hypertension
Known heart rhythm disorder or pacemaker
Lung disease, emphysema, chronic bronchitis, or COPD
Asthma or reactive airways disease
Prior pneumothorax (collapsed lung) or lung surgery
Seizures, epilepsy, or unexplained fainting
Stroke, transient ischemic attack, or other neurologic disorder
Diabetes requiring insulin
Psychiatric disorder requiring inpatient care or medication changes
Recurrent ear or sinus disease, recent ear surgery, or difficulty equalizing pressure
Major surgery within the past 6 months
Currently taking prescription medications that may affect diving
Significant drug or environmental allergies
Pregnant, breastfeeding, or trying to become pregnant
Prior history of decompression sickness or arterial gas embolism
Current tobacco smoker or nicotine product use
Other significant medical condition not listed

Current Medications & Allergies

Symptoms and Recent Health Events

In the past 30 days, have you experienced any of the following? (check all that apply)

Chest pain or unexplained chest discomfort
Shortness of breath at rest or with exertion
Loss of consciousness, blackout, or fainting
New or unexplained dizziness or balance problems
Persistent cough or coughing up blood
Recent febrile illness, influenza-like illness, or COVID-like symptoms
Recent hospitalization or emergency department visit
Recent travel requiring medical treatment

Consent, Authorization, and Certification

I certify that the information on this form is complete and accurate to the best of my knowledge. I understand that failure to disclose medical conditions that could affect my safety during diving may result in injury or death. I acknowledge that a medical examination and physician clearance may be required before participation in diving activities if responses indicate potential risk.

I authorize release of relevant medical information from this form to medical personnel, the diving operator, or emergency responders in the event of a diving-related illness or injury. This authorization expires on:

I authorize emergency medical treatment as necessary in the event of injury or illness while participating in diving activities.

I acknowledge receipt of the facility's privacy practices and understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations.

Medical Clearance Recommendation

If any medical history items or recent symptoms were reported, I understand that I must obtain written clearance from a licensed physician before diving. I acknowledge that this questionnaire does not substitute for a medical examination.

Acknowledgment and Signature

By signing below I attest that I have read and understood this questionnaire, that my answers are accurate and complete, and that I accept the responsibilities described herein. I understand that diving carries inherent risks and that medical clearance is the responsibility of the diver when indicated.

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