To The Participant

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before
participating in recreational diver training. A positive response to a question does not necessarily disqualify you from
diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you
must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO.
If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician
prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines
for Recreational Scuba Diver’s Physical Examination to take to your physician.

Full Name

E-mail Address

D.O.B.

/ /

Course Start Date

/ /

Please complete all the following questions

1.yes no  Could you be pregnant, or are you attempting to become pregnant?
2.yes no  Are you presently taking prescription medications?(with exception of birth control or anti-malarial)
3.yes no  Are you over 45 years of age and can answer Yes to one or more of the following?
 • currently smoke a pipe, cigars or cigarettes
 • have high cholesterol level
 • have a family history of heart attack or stroke
 • are currently receiving medical care
 • high blood pressure
 • diabetes mellitus, even if controlled by diet alone
4.yes no  Asthma, or wheezing with breathing, or wheezing with exercise?
5.yes no  Frequent or severe attacks of hay fever or alergy?
6.yes no  Frequent colds, sinusitis or bronchitis?
7.yes no  Any form of lung disease?
8.yes no  Pneumothorax (collapsed lung)?
9.yes no  Other chest disease or chest surgery?
10.yes no  Behavioral health, mental or psychological problems (Panic attack,fear of closed or open spaces)?
11.yes no  Epilepsy, seizures, convulsions or take medications to prevent them?
12.yes no  Recurring complicated migraine headaches or take medications to prevent them?
13.yes no  Blackouts or fainting (full/partial loss of consciousness)?
14.yes no  Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?
15.yes no  Dysentary or dehydration requiring medical intervention?
16.yes no  Any dive accidents or decompression sickness?
17.yes no  Inability to perform moderate exercise (example:walk 1.6km/1mile within 10mins.)?
18.yes no  Head injury with loss of consciousness in the past five years?
19.yes no  Recurrent back problems?
20.yes no  Back or spinal surgery?
21.yes no  Diabetes?
22.yes no  Back, arm or leg problems following surgery, injury or frature?
23.yes no  High blood pressure or take medicine to control blood pressure?
24.yes no  Heart Disease?
25.yes no  Heart attack?
26.yes no  Angina, heart surgery or blood vessel surgery?
27.yes no  Sinus surgery?
28.yes no  Ear disease or surgery, hearing loss or problems with balance?
29.yes no  Recurrent ear problems?
30.yes no  Bleeding or other blood disorders?
31.yes no  Hernia?
32.yes no  Ulcers or ulcer surgery?
33.yes no  A colostomy or ileostomy?
34.yes no  Recreational drug use or treatment for, or alcoholism in the past five years?

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. yes no


As an anti-spam measure, please type the numbers above in the field above