To the Participant. At its office address as stated under its signature below. Notice of a change in address of one of the parities hereto shall be given in writing to the other party as provided above, but shall be effective only upon actual receipt.
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 freediving and/or scuba 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 participating in diving 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 request that you consult with a physician prior to participating in freediving and/or scuba diving. Your Instructor will supply you with a medical statement and guidelines for Recreational Freediving & Scuba Diving physical examination to 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? ■ currently smoke a pipe, cigars, or cigarettes ■ have a high cholesterol level have a family history of heart attacks or strokes ■ ■ are currently receiving medical care high blood pressure ■ ■ diabetes mellitus, even if controlled by diet alone 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)? Other chest disease or chest surgery? Behavioral health, mental or psychological problems (panic attack, fear of closed or open spaces)? ■ Epilepsy, seizures, convulsions or take medications to prevent them? ■ Recurring migraine headaches or take medications to prevent them? ■ Blackouts or fainting (full/ partial loss of consciousness)? Frequent or severe suffering from motion sickness (seasick, carsick, etc.)? ■ ■ Dysentery or dehydration requiring medical intervention? Any dive accidents or decompression sickness? ■ Inability to perform moderate exercise (example: walk 1.6 km/ one mile within 12 mins.)? ■ Head injury with loss of consciousness in the past five years? ■ ■ ■ Recurrent back problems? Back or spinal surgery? Diabetes? Back, arm or leg problems following surgery, injury or fracture? ■ High blood pressure or take medicat...
