BLUE EXPLORERS DIVE CENTER - MEDICAL STATEMENT
(Confidential information)

Please read carefully before signing.

This is a statement in which you are informed of some risks involved in scuba diving and of the conduct required of you during the scuba diving program. Your signature on this statement is required for you to participate in the scuba diving program offered by ______________________________(instructor) and Blue Explorers Dive Center located in the city of Playa Del Ingles in Gran Canaria and Abades in Tenerife.
Read and discuss statement prior to signing it. You must complete this Medical Statement, which includes the medical-history section, to enroll in the scuba-training program. Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there are dangers. 		   To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem , or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor and the instructor before participation in this program. Improper use of scuba equipment can result in serious injury.
If you have any additional questions regarding this Medical Statement or the Medical history section, review them with us before signing.


MEDICAL HISTORY

To the participant:

The prupose 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 effect your safety while diving and you must seek the advice of your physician.
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 a participating in scuba diving.

- Could you be pregnant or are you attempting to become pregnant?
- Do you regulary take prescription or non prescription medications (with the exception of birth control)?
- Are you 45 years of age and have one or more of the following...
  • Currently smoke a pipe, cigars or cigarettes?
  • Have a high cholesterol level?
  • Have a family history of heart attacks or strokes?
Have you ever had or do you currently have ...
- Asthma or wheezing with breathing or wheezing with exercise?
- Frequent or severe attacks of hayfever or allergy?
- Frequent colds, sinusitis or bronchitis?
- Any form of lung disease?
- Pneumothorax (collapsed lung)?
- History of chest surgery?
- Claustophobia or agoraphobia (fear of closed open spaces)?
- Behavioral health problems?
- Epilepsy, seizures, convulsions or take medications to prevent them?
- Recurring migraine headaches or take medications to prevent them?
- History of blackouts or fainting (full/partial loss of consciousness)?
   - Do you frequently suffer from motion sickness (seasick, carsick, ect.)?
- History of diving accidents or decompression sickness?
- History of recurrent back problems?
- History of back surgery?
- History of diabetes?
- History of back, arm or leg problems following surgery, injury or fracture?
- Inability to perform moderate exercise (walk 1.600 meters within 12 minutes)?
- History of high blood pressure or take medicine to control blood pressure?
- History of any heart disease?
- History of heart attacks?
- Angina or heart surgery or blood vessel surgery?
- History of sinus and ear surgery?
- History of ear disease, hearing loss or problems with balance?
- History of problems equalizing (popping) ears with airplane or mountain travel?
- History or bleeding or other blood disorders?
- History of any type of hernia?
- History of ulcers or ulcer surgery?
- History of colostomy?
- History of drug or alcohol abuse?


The information I have provided about my medical history is accurate to the best of my knowledge.


Signature

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Signature of Parents or Guardian Where Applicable

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