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Diver Medical | Participant Questionnaire

This form is based on the Royal Decrete 550/2020, of 2nd of June, which is regulating the medical suitability to participate in recreational scubadiving or freediving training or activity in Spain.  

You will receive the results by email. In case you will need to get a medical certificate from a doctor, you find attached to the email the necessary forms for your medic.

Title(*)
Title
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Please enter your first name!
Please enter your last name!
Please enter a valid email
Date of birth(*)
Please enter your date of birth!

Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which canRecreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which canbe hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated bya physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. Ifyou have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If youare feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating indive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving.This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuingeducation. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.

 

Are you pregnant or trying to get pregnant?(*)
Are you pregnant or trying to get pregnant?
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If you are pregnant, or trying to become pregnant, you must not dive!

We're looking forward to diving with you again in 9 months, when Dad's on the beach looking after the baby. :) Good luck! 

1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.(*)
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.
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Additional questions:

I have / have had

a. Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
a. Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
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b. Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
b. Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
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c. A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack orA problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack orstroke, OR am taking medication for any heart condition.
c. A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack orA problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack orstroke, OR am taking medication for any heart condition.
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d. Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
d. Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
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e. A diagnosis of COVID-19.
e. A diagnosis of COVID-19.
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2. I am over 45 years of age.(*)
2. I am over 45 years of age.
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Additional questions:

I am over 45 years of age AND

a. I currently smoke or inhale nicotine by other means.
a. I currently smoke or inhale nicotine by other means.
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b. I have a high cholesterol level.
b. I have a high cholesterol level.
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c. I have high blood pressure.
c. I have high blood pressure.
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d. I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heartI have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heartdisease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
d. I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heartI have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heartdisease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
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3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.(*)
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.
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4. I have had problems with my eyes, ears, or nasal passages/sinuses.(*)
4. I have had problems with my eyes, ears, or nasal passages/sinuses.
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Additional questions:

I have / have had

a. Sinus surgery within the last 6 months.
a. Sinus surgery within the last 6 months.
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b. Ear disease or ear surgery, hearing loss, or problems with balance.
b. Ear disease or ear surgery, hearing loss, or problems with balance.
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c. Recurrent sinusitis within the past 12 months.
c. Recurrent sinusitis within the past 12 months.
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d. Eye surgery within the past 3 months.
d. Eye surgery within the past 3 months.
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5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.(*)
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
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6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.(*)
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
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Additional questions:

I have / have had

a. Head injury with loss of consciousness within the past 5 years.
a. Head injury with loss of consciousness within the past 5 years.
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b. Persistent neurologic injury or disease.
b. Persistent neurologic injury or disease.
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c. Recurring migraine headaches within the past 12 months, or take medications to prevent them.
c. Recurring migraine headaches within the past 12 months, or take medications to prevent them.
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d. Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
d. Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
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e. Epilepsy, seizures, or convulsions, OR take medications to prevent them.
e. Epilepsy, seizures, or convulsions, OR take medications to prevent them.
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7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.(*)
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.
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Additional questions:

I have / have had

a. Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
a. Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
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b. Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
b. Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
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c. Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
c. Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
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d. An addiction to drugs or alcohol requiring treatment within the last 5 years.
d. An addiction to drugs or alcohol requiring treatment within the last 5 years.
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8. I have had back problems, hernia, ulcers, or diabetes.(*)
8. I have had back problems, hernia, ulcers, or diabetes.
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Additional questions:

I have / have had

a. Recurrent back problems in the last 6 months that limit my everyday activity.
a. Recurrent back problems in the last 6 months that limit my everyday activity.
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b. Back or spinal surgery within the last 12 months.
b. Back or spinal surgery within the last 12 months.
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c. Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
c. Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
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d. An uncorrected hernia that limits my physical abilities.
d. An uncorrected hernia that limits my physical abilities.
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e. Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
e. Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
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9. I have had stomach or intestine problems, including recent diarrhea.(*)
9. I have had stomach or intestine problems, including recent diarrhea.
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Additional questions:

I have / have had

a. Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
a. Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
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b. Dehydration requiring medical intervention within the last 7 days.
b. Dehydration requiring medical intervention within the last 7 days.
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c. Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
c. Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
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d. Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
d. Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
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e. Active or uncontrolled ulcerative colitis or Crohn’s disease.
e. Active or uncontrolled ulcerative colitis or Crohn’s disease.
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f. Bariatric surgery within the last 12 months.
f. Bariatric surgery within the last 12 months.
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10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).(*)
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).
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Leagal

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