Reef Keepers Maldives Reef Keepers Maldives

Diving Medical Questionnaire

Participant Form

Recreational diving requires good physical and mental health. If you have any of the conditions listed below, you should be evaluated by a physician before diving.

Instructions: Answer all questions. If you answer YES to a question that references a “Box”, complete the additional questions that will appear.

Note for women: if you are pregnant or trying to become pregnant, do not dive.

1. I have had lung, respiratory, cardiac and/or blood problems that affected my normal physical or mental performance.

BOX A — I HAVE/HAVE HAD:

Answer these if you responded YES to question 1.

Chest or heart surgery, valve repair/replacement, stent, pacemaker, or pneumothorax.
Asthma, shortness of breath, severe allergies, hay fever or congested airways in the last 12 months that limited physical activity.
Heart condition (angina, chest pain, heart failure, heart attack) or I take medication for cardiac conditions.
Recurrent bronchitis and cough in the last 12 months, OR a diagnosis of emphysema.
Pulmonary, cardiac or blood-related symptoms in the last 30 days that limited physical performance.
2. I am over 45 years of age.

BOX B — I AM OVER 45 AND:

I smoke or inhale nicotine in other ways.
I have high cholesterol levels.
I have high blood pressure.
Family history of heart disease or sudden death before age 50 among close relatives.
3. I struggle with moderate exercise (e.g., walking 1 mile in 14 minutes or swimming 200 m), or I have been unable to exercise in the last 12 months for health reasons.
4. I have had problems with eyes, ears, or sinuses.

BOX C — I HAVE/HAVE HAD:

Sinus surgery within the last 6 months.
Ear disease, ear surgery, hearing loss, or balance problems.
Recurrent sinusitis in the last 12 months.
Eye surgery within the last 3 months.
5. I have had surgery within the last 12 months OR I still have problems due to past surgery.
6. I have lost consciousness, had migraines, seizures, stroke, significant head injury, or I have a chronic neurological disease.

BOX D — I HAVE/HAVE HAD:

Head injury with loss of consciousness within the last 5 years.
Chronic neurological condition.
Recurrent migraine in the last 12 months or I take medication to prevent it.
Loss of consciousness or fainting within the last 5 years.
Epilepsy, seizures, or I take medication to prevent them.
7. I am currently in therapy (or have been in the last 5 years) for psychological problems, panic attacks, addictions or learning disorders.

BOX E — I HAVE/HAVE HAD:

Behavioral or mental problems requiring medical/psychiatric therapy.
Depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder.
Diagnosis of mental illness or learning disorder requiring ongoing care.
Drug or alcohol dependence requiring therapy in the last 5 years.
8. I have had back problems, hernias, ulcers or diabetes.

BOX F — I HAVE/HAVE HAD:

Recurring back problems in the last 6 months that limit daily life.
Back/spine surgery within the last 12 months.
Controlled diabetes or gestational diabetes in the last 12 months.
Uncorrected hernia that limits physical abilities.
Active ulcers, healing issues or ulcer surgery in the last 6 months.
9. I have had gastric or intestinal problems, including recent diarrhea.

BOX G — I HAVE HAD:

Stoma surgery and I do not have medical authorization to perform physical activity.
Dehydration requiring medical intervention within the last 7 days.
Untreated active gastric or intestinal ulcers, or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn’s disease.
Bariatric surgery within the last 12 months.
10. I am taking prescription medicines (excluding contraceptives or antimalarials other than mefloquine).

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