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Medical Questionnaire
Christchurch Freediving Club.
Please read carefully before submitting.
To freedive safety you must not be extremely overweight or out of condition. A person with heart trouble, a cold, epilepsy, asthma, or is under the influence of drugs or alcohol should not dive. If taking medication consult your doctor and your instructor before participating in this programme.
You must learn from your instructor the safety rules regarding breathing and equalization while freediving.
If you have any additional questions regarding this medical statement or the history section, review them with your instructor before signing.
The purpose of a medical statement is to find out if you should be examined by a doctor before participating in freediving. A positive response to a question doesn’t disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving and you must seek the advice of your doctor.
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* Indicates required question
Your name
*
Your answer
Date of birth
*
MM
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DD
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YYYY
Gender
*
Your answer
Medical history
Please answer the following questions on your past and present medical history by checking 'yes' or 'no', if you are unsure, answer 'yes'. If any of these items apply to you we must request that you consult with your doctor.
Neurological conditions
*
Any history of seizure disorder, stroke, brain surgery, black out, severe migraine headaches, or aneurysm of the brain’s blood vessels.
Yes
No
Cardiovascular conditions
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Heart attack, heart surgery, irregular heartbeat, uncontrolled elevated blood pressure.
Yes
No
Pulmonary conditions
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Any history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breathe.
Yes
No
Ear conditions
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Permanent holes of the eardrums, history of ruptured eardrum, severely impaired hearing or hearing loss in one or both ears, or ear surgery.
Yes
No
Sinus conditions
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Tumor, polyps, cysts of the sinus cavities or nasal passages, sinus surgery, or persistent sinus infections.
Yes
No
Asthma
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History of asthma or asthma attacks, history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any conditions requiring medications and/or use of an inhaler for control of wheezing
Yes
No
Diabetes mellitus
*
Especially Type I Diabetes (Insulin dependent) or Type II Diabetes, which requires insulin or oral medication for control. Any form of Diabetes that is unstable or produces episodes of hypoglycemia (low blood sugar reactions) hyperglycemia (extremely high blood sugar) or if there is related kidney disease, eye disease, heart disease or blood vessel disease. Also, of history of elevated blood sugar during pregnancy.
Yes
No
Pregnancy
*
Are you presently pregnant
Yes
No
Freediving/scuba diving conditions
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Previous history of a diving accident, decompression sickness, decompression of the inner ear or air embolus
Yes
No
Medication
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Do you take any medication on a regular basis either over the counter or prescribed by a physician.
Yes
No
General medical problems
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Any physical and / or emotional condition not mentioned that might affect your safety in an underwater environment or affect your judgment under times of physical or emotional stress
Yes
No
Statement
*
THE INFORMATION I HAVE PROVIDED ABOUT MY MEDICAL HISTORY IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
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