CONTINUING EDUCATION STUDENT SCUBA DIVER

Medical Self-Assessment

The 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.

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.

If your self-assessment requires to be assessed by medical practitioner prior to participating in training. Please download this Other Courses Medical Form and take to your physician.

Could you be pregnant, or are you attempting to become pregnant

Are you presently taking prescription medications?
_{(with the exception of birth control or anti-malarial)}

Are you over 45 years of age AND can answer YES to one or more of the following questions?

Currently smoke or inhale nicotine by other methods
Have high cholesterol level
Have high blood pressure
Have had a close blood relative die suddenly of cardiac disease or stroke before the age of 50 , OR have a family history of heart disease before the age of 50( including abnormal heart rhythms, coronary artery disease or cardiomyopathy

Have you ever had or do you currently have:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung) and/or Chronic Lung disease?

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits physical activity/exercise?

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition

Recurrent bronchitis and currently coughing within the past 12 months, Or have been diagnosed with Emphysema?

Symptoms affecting my lungs, heart and/or blood in the last 30 days that impair my physical or mental performance?

Sinus surgery within the last 6 months?

Ear disease or surgery, hearing loss or problems with balance?

Recurrent sinusitis within the past 12 months?

Eye surgery within the past 3 months?

Head injury with loss of consciousness in the past five years?

Persistent Neurologic injury or disease?

Recurring migraine headaches within the past 12 months, or take medication to prevent them?

Blackout or fainting, full or partial loss of consciousness within the last 5 years?

Epilepsy, seizures, convulsions or take medications to prevent them?

Behavioural health, mental or psychological problems requiring medical/psychiatric treatment?

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar requiring medication/psychiatric treatment?

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care?

An addiction to drugs or alcohol requiring treatment in the last 5years?

Recurrent back problems in the last 6 months that limit my everyday activity?

Back or spinal surgery in the last 12 months?

Diabetes, drug or diet controlled, or gestational diabetes within the last 2 months?

An uncorrected hernia that limits my physical activity?

Active or un treated ulcers, problem wounds, or ulcer surgery within the last 6 months?

Ostomy surgery and do not have medical clearance to swim or engage in physical activity?

Dehydration requiring medical intervention in the last 7 days?

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months?

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD)?

Active uncontrolled ulcerative colitis or Crohns disease?

Bariatric surgery within the last 12 months?

I struggle to perform moderate exercise (for example, walk 1.6km in 14 min or swim 200m without resting), Or I have been unable to participate in a normal physical activity due to fitness or health reasons in the past 12 months

Continuing Education Student Scuba Diver

CONTINUING EDUCATION STUDENT SCUBA DIVER

Medical Self-Assessment

Could you be pregnant, or are you attempting to become pregnant

Are you presently taking prescription medications?
_{(with the exception of birth control or anti-malarial)}

Are you over 45 years of age AND can answer YES to one or more of the following questions?

Have you ever had or do you currently have:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung) and/or Chronic Lung disease?

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits physical activity/exercise?

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition

Recurrent bronchitis and currently coughing within the past 12 months, Or have been diagnosed with Emphysema?

Symptoms affecting my lungs, heart and/or blood in the last 30 days that impair my physical or mental performance?

Sinus surgery within the last 6 months?

Ear disease or surgery, hearing loss or problems with balance?

Recurrent sinusitis within the past 12 months?

Eye surgery within the past 3 months?

Head injury with loss of consciousness in the past five years?

Persistent Neurologic injury or disease?

Recurring migraine headaches within the past 12 months, or take medication to prevent them?

Blackout or fainting, full or partial loss of consciousness within the last 5 years?

Epilepsy, seizures, convulsions or take medications to prevent them?

Behavioural health, mental or psychological problems requiring medical/psychiatric treatment?

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar requiring medication/psychiatric treatment?

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care?

An addiction to drugs or alcohol requiring treatment in the last 5years?

Recurrent back problems in the last 6 months that limit my everyday activity?

Back or spinal surgery in the last 12 months?

Diabetes, drug or diet controlled, or gestational diabetes within the last 2 months?

An uncorrected hernia that limits my physical activity?

Active or un treated ulcers, problem wounds, or ulcer surgery within the last 6 months?

Ostomy surgery and do not have medical clearance to swim or engage in physical activity?

Dehydration requiring medical intervention in the last 7 days?

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months?

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD)?

Active uncontrolled ulcerative colitis or Crohns disease?

Bariatric surgery within the last 12 months?

I struggle to perform moderate exercise (for example, walk 1.6km in 14 min or swim 200m without resting), Or I have been unable to participate in a normal physical activity due to fitness or health reasons in the past 12 months

Secure a $200 QLD Getaway Discount Voucher for a trip or course with Pro Dive Cairns!

Continuing Education Student Scuba Diver

CONTINUING EDUCATION STUDENT SCUBA DIVER

Medical Self-Assessment

Could you be pregnant, or are you attempting to become pregnant

Are you presently taking prescription medications?(with the exception of birth control or anti-malarial)

Are you over 45 years of age AND can answer YES to one or more of the following questions?

Have you ever had or do you currently have:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung) and/or Chronic Lung disease?

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits physical activity/exercise?

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition

Recurrent bronchitis and currently coughing within the past 12 months, Or have been diagnosed with Emphysema?

Symptoms affecting my lungs, heart and/or blood in the last 30 days that impair my physical or mental performance?

Sinus surgery within the last 6 months?

Ear disease or surgery, hearing loss or problems with balance?

Recurrent sinusitis within the past 12 months?

Eye surgery within the past 3 months?

Head injury with loss of consciousness in the past five years?

Persistent Neurologic injury or disease?

Recurring migraine headaches within the past 12 months, or take medication to prevent them?

Blackout or fainting, full or partial loss of consciousness within the last 5 years?

Epilepsy, seizures, convulsions or take medications to prevent them?

Behavioural health, mental or psychological problems requiring medical/psychiatric treatment?

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar requiring medication/psychiatric treatment?

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care?

An addiction to drugs or alcohol requiring treatment in the last 5years?

Recurrent back problems in the last 6 months that limit my everyday activity?

Back or spinal surgery in the last 12 months?

Diabetes, drug or diet controlled, or gestational diabetes within the last 2 months?

An uncorrected hernia that limits my physical activity?

Active or un treated ulcers, problem wounds, or ulcer surgery within the last 6 months?

Ostomy surgery and do not have medical clearance to swim or engage in physical activity?

Dehydration requiring medical intervention in the last 7 days?

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months?

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD)?

Active uncontrolled ulcerative colitis or Crohns disease?

Bariatric surgery within the last 12 months?

I struggle to perform moderate exercise (for example, walk 1.6km in 14 min or swim 200m without resting), Or I have been unable to participate in a normal physical activity due to fitness or health reasons in the past 12 months

Secure a $200 QLD Getaway Discount Voucher for a trip or course with Pro Dive Cairns!

Are you presently taking prescription medications?
_{(with the exception of birth control or anti-malarial)}