Participant:   Course: 
MEDICAL STATEMENT
Participant Record (Confidential Information)
Please read carefully before signing.
This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered

by ______________________________(instructor) and

Huron Scuba, Snorkel and Adventure Travel Inc.. located in the city of Ann Arbor, state/province of Michigan.

    Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian.
    Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are
  increased risks.
    To scuba dive safely, you should 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. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.
    If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing.
Divers Medical Questionnaire
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 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 engaging in dive 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 must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's 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 attack or stroke
 ___ 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 complicated 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 medicine to control blood pressure?
____Heart disease?
____Heart attack?
____Angina, heart surgery or blood vessel surgery?
____Sinus surgery?
____Ear disease or surgery, hearing loss or problems with balance?
____Recurrent ear problems?
____Bleeding or other blood disorders?
____Hernia?
____Ulcers or ulcer surgery ?
____A colostomy or ileostomy?
____Recreational drug use or treatment for, or alcoholism in the past five years?
The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.
_______________________________________ _________________ _______________________________________ _________________
Signature Date Signature of Parent or Guardian Date
PRODUCT No. 10063 (Rev. 06/07) Ver. 2.01      

STUDENT

Please print legibly.
Name ________________________________________ Birth Date ________________ Age __________
First             Initial             Last                                   Day/Month/Year  
Mailing Address ______________________________________________________________________
City ______________________________ State/Province/Region ____________________
Country _________________________________________ Zip/Postal Code ____________________
Home Phone (_______) ______________________________ Business Phone (______) ____________________
Fax (______) ____________________ Email ________________________________________
Name and address of your family physician
Physician _________________________________________ Clinic/Hospital _________________________________________
Address __________________________________________________________________________________
Date of last physical examination _________________________________________
Name of examiner _________________________________________ Clinic/Hospital _________________________________________
Address __________________________________________________________________________________
Phone (______) ____________________ Email _________________________________________
Were you ever required to have a physical for diving? [ ] Yes [ ] No If so, when? _________________________________________



PHYSICIAN

This person applying for training or is presently certified to engage in scuba (self-contained underwater breathing apparatus) diving. Your opinion of the applicant's medical fitness for scuba diving is requested. There are guidelines attached for your information and reference.
 
Physician's Impression
[ ] I find no medical conditions that I consider incompatible with diving.
[ ] I am unable to recommend this individual for diving.
 
Remarks _________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

_______________________________________________________________ Date _________________________________________
Physician's Signature or Legal Representative of Medical Practitioner Day/Month/Year
Physician _________________________________________ Clinic/Hospital _________________________________
Address __________________________________________________________________________________
Phone (      ) ____________________ Email _________________________________________