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Comprehensive
information about diving and undersea medicine for the
non-medical diver, the non-diving physician and the specialist.
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MEDICAL STANDARDS
MEDICAL REQUIREMENTS
All divers should have have passed a current diving physicalexamination and have been declared by the examining physician to be fit to engage in diving activities as may be limited or restricted in the medical evaluation report. All medical evaluations required by this standard shall be performed by, or under the direction of, a licensed physician of the applicant diver's choice, preferably one trained indiving/undersea medicine. The diver should be free of any chronic disabling disease and be free of any conditions contained in the list of conditions for which restrictions from diving are generally recommended.
- Frequency of Medical Evaluations
before a diver may begin diving, unless an equivalent initial medical evaluation has been given within the preceding 3 years (2 years if over the age of 40). thereafter, at three year intervals up to age 40 and every two years after the age of 40. after any major injury or illness, or any condition requiring hospitalization for more than 24 hours requires clearance to return to diving from a physician. If the injury or illness is pressurerelated then the clearance to return to diving must come from a physician trained in diving medicine.
Applicant's release of medical information Medical history Diving physical examination Conditions for which Restriction from Diving is Recommended (Adapted from Bove/Davis's "Medical Examination of Sport Scuba Divers", 1986/1993)
Medical HistoryInitial examination and first examination over age forty:
Chest X-ray
12 lead EKG
Pulmonary function
Audiogram
Visual acuity
Complete blood count (CBC)
Blood chemistry
Urinalysis
Any further tests deemed necessary by the physician to qualify the patient for scuba diving.
Medical HistoryPeriodic re-examination (every 3 years under 40, every 2 years over 40):
Pulmonary function
Audiogram
Visual acuity
Complete blood count (CBC)
Blood chemistry
Urinalysis
Any further tests deemed necessary by the physician to qualify the patient for scuba diving.
Physician's Written Report.
After any medical examination relating to the individual's fitness to dive, the diver shall obtain a written report prepared by the examining physician, which shall contain the examining physician's opinion of the individual's fitness to dive, including any recommendedrestrictions or limitations.
DIVING MEDICAL EXAM OVERVIEW FOR THE EXAMINING PHYSICIAN
TO THE EXAMINING PHYSICIAN:
This person, _____________________, requires
a medical examination to assess his/her fitness for certification as a
Sport Scuba Diver. His /her answers on the Diving Medical History Form
(attached), may indicate potential health or safety risks as noted. Your
evaluation is requested on the attached scuba Diving Fitness Medical Evaluation
Report.
If you have questions about diving medicine,
you may wish to consult one of the references on the attached list or contact
a physician competent in Diving Medicine. Please contact the undersigned
Diving Medical Consultant if you have any questions or concerns about
diving medicine. Thank you for your assistance.
Ernest S Campbell, MD, FACS (or,
insert Diving Medical Consultant for your area)
scubadoc@scuba-doc.com
GUIDELINES FOR PHYSICIANS - Medical Fitness to Dive
PADI
Medical Statement
Physical Exam Form
References
OTHER SELECTED REFERENCES IN DIVING MEDICINE
DIVING MEDICINE, 1997. A. Bove and J. Davis. W.B. Saunders Company, Philadelphia
DIVING AND SUBAQUATIC MEDICINE, Fourth Edition,
2002. C. Edmonds, C. Lowery and J. Pennefather.
MEDICAL EXAMINATION OF SPORT SCUBA DIVERS,
3rd Edition, A.A. Bove, MD, PhD (ed.). Best Publishing Company, P.O.
Box 30100, Flagstaff, AZ 86003-0100.
NOAA DIVING MANUAL, NOAA. Superintendent
of Documents, U.S. Government Printing Office, Washington, D.C.
SCUBA DIVING IN SAFETY AND HEALTH, C.W.
Deuker. Madison Publishing Associates, Diving Safety Digest, P.O. Box 2735,
Menlo Park, CA 94026
THE PHYSICIAN'S GUIDE TO DIVING MEDICINE,
C.W. Shilling, C.B. Carlston and R.A. Mathias. Plenum Press, New York,
NY (Available through the Undersea and Hyperbaric Medical Association,
Bethesda, MD)
U.S. NAVY DIVING MANUAL. Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
Compressed-gas diving (scuba) can be strenuous
and hazardous. A special risk is present if air-filled spaces such as the
the middle ear, sinuses or lung segments do not readily equalize as the
pressure changes. The most common cause of difficulty is inability
to equalize the middle ear. Most fatalities involve deficiencies in decision-making,
judgement, emotional stability or physical fitness. Please consult the
following list of conditions which can restrict candidates from diving.
(From Bove/Davis, Medical Examination od Sport Scuba Divers, 1986/1993.)
1. Tympanic membrane perforation or aeration
tube
2. Inability to auto-inflate the middle ears
3. External ear exostoses or osteomas adequate
to prevent external ear canal pressure equilibration
4. Meniere's Disease or other chronic vertiginous
conditions, status post-surgery, such as
subarachnoid endolymphatic shunt for Meniere's
Disease
5. Stapedectomy and middle ear prosthesis*Recent
studies refute this. See below.
6. Chronic mastoiditis or mastoid fistula
7. Any oral or maxillofacial deformity that
interferes with the retention of the regulator mouthpiece
8. Corrected near visual acuity not adequate
to see tank pressure gauge, watch, decompression tables, and compass underwater.
Uncorrected visual acuity not adequate to see the diving buddy or locate
the boat in case corrective lenses are lost underwater
9. Recent ocular surgery
10. Claustrophobia of a degree to predispose
to panic
11. Suicidal ideation
12. Significant anxiety states
13. Psychosis
14. Severe depression
15. Manic states
16. Alcoholism
17. Mood-altering drug use
18. Improper motivation for diving
19. Episodic loss of consciousness
20. History of seizure. Seizure in early childhood
must be evaluated individually
21. Migraine
22. History of cerebrovascular accident or
transient ischemic attack
23. History of spinal cord trauma with neurologic
deficit - whether fully recovered or not.
24. Degenerative Nervous system disorders
25. Brain tumor with or without surgery
26. Intracranial aneurysm or other vascular
malformation
27. History of neurological decompression
sickness with residual deficit
28. Head injury with sequelae
29. History of intracranial surgery
30. Sickle cell disease , Congenital
spherocytosis
31. Polycythemia or leukemia
32. Unexplained anemia
33. History of myocardial infarction
34. Angina or other evidence of coronary artery
disease
35. Unrepaired cardiac septal defects(PFO)
36. Aortic stenosis or mitral stenosis
37. Complete heart block
38. Sinus bradycardia
39. Exercised-induced tachyarrhythmias
40. Wolf-Parkinson-White (WPW) Syndrome with
paroxysmal atrial tachycardia or syncope
41. Fixed-rate pacemakers (Inability
to respond to stress)
42. Drugs such as beta blockers which inhibit
the normal cardiovascular response to exercise tolerance
43. Peripheral vascular disease, arterial
or venous, severe enough to limit exercise tolerance
44. Hypertension with end-organ finding -
retinal, cardiac, renal or vascular
45. History of spontaneous pneumothorax
46. Bronchial asthma. History of childhood
asthma requires special studies
47. Exercise or cold air-induced asthma
48. X-ray evidence of pulmonary blebs, bullae,
or cysts
49. Chronic obstructive pulmonary disease
50. Insulin-dependent diabetes mellitus. Diet
or oral medication-controlled diabetes mellitus if there is a history of
hypoglycemic episodes
51. Any abdominal wall hernia with potential
for gas-trapping until surgically corrected
52. Paraesophageal or incarcerated sliding
hiatal hernia
53. Sliding hiatus hernia if symptomatic due
to reflux esophagitis
54. Pregnancy
55. Osteonecrosis. A history consistent with
a high risk of dysbaric osteonecrosis
56. Any condition requiring ingestion of the
following medication: antihistamines, bronchodilators, steroids, barbiturates,
phenytoin, mood-altering drugs, insulin
______________________________________________________________________________
MEDICAL EVALUATION
OF FITNESS FOR SCUBA DIVING REPORT
____________________________ __________________
Name of Applicant (Print or Type) Date (Month/Day/Year)
To The PHYSICIAN:
This person is an applicant for training or
is presently certified to engage in diving with self-contained underwater
breathing apparatus (scuba). This is an activity which puts unusual stress
on the individual in several ways. Your opinion on the applicant's medical
fitness is requested. Scuba diving can require heavy exertion. The diver
must be free of cardiovascular and respiratory disease. An absolute requirement
is the ability of the lungs, middle ear and sinuses to equalize pressure.
Any condition that risks the loss of consciousness should disqualify the
applicant.
TESTS: Please initial that the following tests
were completed.
[ ] Initial Examination [ ] Re-examination
or first over age 40
_____Medical History
_____Chest X-Ray
_____12 Lead EKG
_____Pulmonary function
_____Audiogram
_____Visual acuity
_____Complete blood count (CBC)
_____Blood chemistry
_____Urinalysis
RECOMMENDATION:
[ ] APPROVAL. I find no medical condition(s)
which I consider incompatible with diving.
[ ] RESTRICTED ACTIVITY APPROVAL. The applicant
may dive in certain circumstances as described in REMARKS.
[ ] FURTHER TESTING REQUIRED. I have encountered
a potential contraindication to diving. Additional medical tests must be
performed before a final assessment can be made. See REMARKS.
[ ] REJECT. This applicant has medical condition(s)
which, in my opinion, clearly would constitute unacceptable hazards to
health and safety in diving.
Remarks:
________________________________________________________
_________________________________________________________________________
_________________________________________________________________
_________________________________________________________________
______________________________________________________________________________________________________________________________
_________________________________________________________________
___
I have discussed the patient's medical condition(s)
which would not seriously interfere with diving but which may seriously
compromise subsequent health. The patient understands the nature of the
hazards and the risks involved in diving with these defects.
___________________________________________________________
M.D.
Date Signature
__________________________________________________________________
Name (Print or Type)
_________________________________________________________________
_
Address
______________________________
Telephone Number
My familiarity with applicant is:
O With this exam only
O Regular Physician for _____ years
O Other (describe)__________________________________________________
_________________________________________________________________
_
My familiarity with diving medicine:
O On attached list of physicians
O Other (describe)__________________________________________________
_________________________________________________________________
_
_________________________________________________________________
_
APPLICANT'S RELEASE OF MEDICAL INFORMATION
FORM
I authorize the release of this information
and all medical information
subsequently acquired in association with
my diving to the _________________
_____________________ Diving Medical Consultant
(place) ________________________________ on
(date)__________.
Signature of Applicant ____________________________________________
-
DIVING MEDICAL HISTORY FORM
(To Be Completed By Applicant-Diver)
Name ______________________________________
Sex ____ Age ___ Wt.___ Ht. ___
Date ___/___/___
(Mo/Day/Yr)
TO THE APPLICANT:
Scuba diving makes considerable demands on
your physical and emotional condition. Diving with particular defects
amounts to asking for trouble not only for yourself, but to anyone coming
to youraid if you get into difficulty in the water. Therefore, it is prudent
to meet certain medical and physical requirements before beginning
a diving or training program.
Your answers to the questions are more important, in many instances, in determining your fitness than what the physician may see, hear or feel when you are examined. Obviously, you should giveaccurate information or the medical screening procedure becomes useless.
This form shall be kept confidential. If you believe any question amounts to invasion of your privacy, you may elect to omit an answer, provided that you shall subsequently discuss that matter with yourown physician and he/she must then indicate, in writing, that you have done so and that no health hazard exists.
Should your answers indicate a condition which
might make diving hazardous, you will be asked to review the matter
with your physician. In such instances, his/her written authorization will
be required in order for further consideration to be given to your
application. If your physician concludes that diving would involve
undue risk for you, remember that he/she is concerned only with yourwell-being
and safety. Respect the advice and the intent of this medical history form.
Please indicate whether or not the following apply to you
Comments
1. Y N Convulsions, seizures,
or epilepsy
2. Y N Fainting spells or dizziness
3 Y N Been addicted to drugs
4 Y N Diabetes
5 Y N Motion sickness or sea/air sickness
6 Y N Claustrophobia
7 Y N Mental disorder or nervous breakdown
8 Y N Are you pregnant?
9 Y N Do you suffer from menstrual problems?
10 Y N Anxiety spells or hyperventilation
11 Y N Frequent sour stomachs, nervous stomachs or vomiting spells
12 Y N Had a major operation
13 Y N Presently being treated by a physician
14 Y N Taking any medication regularly (even nonprescription)
Please indicate whether or not the following apply to you
Comments
15 Y N Been rejected or restricted from sports
16 Y N Headaches (frequent and severe)
17 Y N Wear dental plates
18 Y N Wear glasses or contact lenses
19 Y N Bleeding disorders
20 Y N Alcoholism
21 Y N Any Problems related to diving
22 Y N Nervous tension or emotional problems
23 Y N Take tranquilizers
24 Y N Perforated ear drums
25 Y N Hay fever
26 Y N Frequent sinus trouble,
frequent drainage from the nose,
post-nasal drip, or stuffy nose
27 Y N Frequent earaches
28 Y N Drainage from the ears
29 Y N Difficulty with your ears in airplanes or on mountains
30 Y N Ear surgery
31 Y N Ringing in your ears
32 Y N Frequent dizzy spells
33 Y N Hearing problems
34 Y N Trouble equalizing pressure in your ears
35 Y N Asthma
36 Y N Wheezing attacks
37 Y N Cough (chronic or recurrent)
38 Y N Frequently raise sputum
39 Y N Pleurisy
40 Y N Collapsed lung (pneumothorax)
41 Y N Lung cysts
42 Y N Pneumonia
43 Y N Tuberculosis
44 Y N Shortness of breath
45 Y N Lung problem or abnormality
46 Y N Spit blood
47 Y N Breathing difficulty
after eating particular foods,after exposure to
particular pollens or animals
48 Y N Are you subject to bronchitis
49 Y N Subcutaneous emphysema (air under the skin)
50 Y N Air embolism after diving
51 Y N Decompression sickness
52 Y N Rheumatic fever
53 Y N Scarlet fever
Please indicate whether or not the following apply to you
Comments
54 Y N Heart murmur
55 Y N Large heart
56 Y N High blood pressure
57 Y N Angina (heart pains or pressure in the chest)
58 Y N Heart attack
59 Y N Low blood pressure
60 Y N Recurrent or persistent swelling of the legs
61 Y N Pounding, rapid heartbeat or palpitations
62 Y N Easily fatigued or short of breath
63 Y N Abnormal EKG
64 Y N Joint problems, dislocations or arthritis
65 Y N Back trouble or back injuries
66 Y N Ruptured or slipped disk
67 Y N Limiting physical handicaps
68 Y N Muscle cramps
69 Y N Varicose veins
70 Y N Amputations
71 Y N Head injury causing unconsciousness
72 Y N Paralysis
73 Y N Have you ever had an adverse reaction to medication?
74 Y N Do you smoke?
75 Y N Have you ever had
any other medical problems not listed? If so,
please list or describe below;
I certify that the above answers and information
represent an accurate and complete description of my medical history.
__________________________________________________________________
Signature Date
APPENDIX 4
MEDICAL HISTORY QUESTIONS EVALUATION FORM
(Answer Screening Aid)
2 - B 22 - B 42 - B 62 - B
3 - B 23 - B 43 - B 63 - B
4 - B 24 - C 44 - B 64 - B
5 - C 25 - B 45 - B 65 - B
6 - B 26 - B 46 - B 66 - B
7 - B 27 - B 47 - B 67 - B
8 - A 28 - B 48 - B 68 - B
9 - B 29 - B 49 - B 69 - B
10 - B 30 - B 50 - B 70 - B
11 - B 31 - B 51 - B 71 - B
12 - B 32 - B 52 - B 72 - B
13 - B 33 - B 53 - B 73 - C
14 - B 34 - C 54 - B 74 - C
15 - B 35 - B 55 - B 75 - B
16 - B 36 - B 56 - B
17 - C 37 - B 57 - A
18 - B 38 - B 58 - B
19 - B 39 - B 59 - B
20 - B 40 - B 60 - B
When a "Yes" answer is checked:
A = Absolute contraindication to diving;
B = Relative contraindication to diving, requires careful review by
physician;
C = Of interest, not a contraindication.
PHYSICAL SCREENING (to be filled out by candidate):
1. HAVE YOU HAD ANY BLOOD PRESSURE OR HEART PROBLEMS?
Y/N
2. DO YOU HAVE A HISTORY OF PAIN OR PRESSURE IN YOUR CHEST?
Y/N
3. HISTORY OF PAIN IN NECK, ARMS, OR SHOULDERS WHEN EXERCIZING?
Y/N
4. HAS ANYONE IN YOUR FAMILY HAD HEART PROBLEMS PRIOR TO AGE 50?
Y/N
5. ARE YOU ACCUSTOMED TO EXERCIZE?
Y/N
6. ARE YOU BREATHLESS AFTER MILD EXERCIZE?
Y/N
7. HAVE YOU EVER HAD HEAT EXHAUSTION OR HEAT STROKE?
Y/N
8. DO YOU EVER GET FAINT OR DIZZY?
Y/N
9. DO YOU HAVE BONE, JOINT, OR BACK PROBLEMS?
Y/N
10. ANY MEDICAL CONDITION THAT MIGHT INTERFERE WITH EXERCISE?
Y/N
SIGNATURE OF CANDIDATE:
MEDICAL RECORD
REPORT OF MEDICAL EXAMINATION DATE OF EXAM
1. LAST NAME-FIRST NAME-MIDDLE NAME
2. HOME ADDRESS(Number,street, city,
state, zip)
3. EMERGENCY CONTACT (Name and address
of contact)
4 DATE OF BIRTH
5. AGE 6. SEX
MALE FEMALE
7. PLACE OF BIRTH
8. RACE
WHITE
BLACK
AMERICAN INDIAN/
ALASKA NATIVE
HISPANIC
ASIAN/PACIFIC
ISLANDER
9. NAME OF EXAMINING FACILITY OR EXAMINER,
ADDRESS
10. PURPOSE OF EXAMINATION
11. CLINICAL EVALUATION
(check each item in appropriate column,
enter "NE" if not evaluated.)
NORMAL
ABNORMAL
NE
A. HEAD, FACE, NECK & SCALP
B. EARS-GENERAL (EXTERNAL CANALS)
C. DRUMS (PERFORATION)
D. NOSE
E. SINUSES
F. MOUTH AND THROAT
G. EYES-GENERAL
H. OPTHALMOSCOPIC (Strength,
range of motion)
I. PUPILS (Equality & reaction)
J. OCULAR MOTILITY
(Associated parallel movements nystagmus)
K. LUNGS AND CHEST
L. HEART(Thrust, size, rythm, sounds)
M. VASCULAR SYSTEM(Variscosities)
N. ABDOMEN AND VISCERA(Include hernia)
O. PROSTATE(Over 40 or clinically indicated)
P. TESTICULAR
Q. ANUS AND RECTUM (Hemorrhoids, Fistulae)
(Hemocult Results)
R. ENDOCRINE SYSTEM
S. G-U SYSTEM
T. UPPER EXTREMITIES(Stength, range of motion)
U. FEET
V. LOWER EXTREMITIES(Except feet)
W. SPINE, OTHER MUSCULOSKELETAL
X. IDENTIFYING MARKS, SCARS, TATTOOS
Y. SKIN, LYMPHATICS
Z. NEUROLOGIC
AA. PSYCHIATRIC(Specify any personality deviation)
BB. BREASTS
CC. PELVIC
NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment.
12. DENTAL(Place appropriate symbols, shown in examples, above or below number of upper and lower teeth) REMARKS AND ADDITIONAL DENTAL
0 / Non- X X X X Replaced ( X ) Fixed DEFECTS AND DISEASES
1 2 3 Restorable 1 2 3 Restorable 1 2 3 Missing 1 2 3 by 1 2 3 Partial
32 31 30 teeth 32 31 30 teeth 32 31 30 teeth 32 31 30 Dentures 32 31 30 Dentures
0 / X X X X ( X )
RIGHT
1
2 3 4
5 6 7
8
9 10
11 12 13
14 15 16
LEFT
32 31
30 29 28
27 26 25 24
23 22 21
20 19 18
17
13. TEST RESULTS(Copies are preferred as attachments)
A. URINALYSIS: (1) SPECIFIC GRAVITY
B. CHEST X-RAY OR PPD(Place, date, film number
and result)
C. URINE ALBUMIN
MICROSCOPIC
URINE SUGAR
D. SYPHILIS SEROLOGY(Specify test used
& results)
E. EKG
F. BLOOD TYPE AND RH FACTOR
G. OTHER TESTS
MEASUREMENTS AND OTHER FINDINGS
14. HEIGHT 15. WEIGHT 16. COLOR HAIR 17. COLOR EYES
18. BUILD
SLENDER MEDIUM HEAVY OBESE
19. TEMPERATURE
20. BLOOD PRESSURE 21. PULSE(Arm at heart level)
A. SYS.
B. Diast.
22. DISTANT VISION
23. REFRACTION
24. NEAR VISION
RIGHT 20/ CORRECTED TO 20/ BY S. CX CORR. TO BY
LEFT 20/ CORRECTED TO 20/ BY S. CX CORR. TO BY
25. HETEROPHORIA (Specify distance)
26. ACCOMODATION 27. COLOR VISION(Test used and result) 28. DEPTH PERCEPTION(Test used and score) UNCORRECTED
RIGHT LEFT CORRECTED
29. FIELD OF VISION 30. NIGHT VISION(Test used and score) 31. RED LENS TEST 32. INTRAOCULAR TENSION
RIGHT LEFT RIGHT LEFT
33. HEARING 34. AUDIOMETER
35. PHSYCHOLOGICAL AND PSYCHOMOTER
250 500 1000 2000 3000 4000 6000 8000 (Test used and score)
RIGHT WV /15 SV /15 256 512 1024 2048 2896 4096 6144 8192
RIGHT LEFT WV /15 SV /15 LEFT
36. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY
(Use additional sheets if necessary)
37. SUMMARY OF DEFECTS AND DIAGNOSES (List
diagnoses with item numbers)
38. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS
INDICATED(Specify) 39A. PHYSICAL PROFILE
P U L H E S
46. EXAMINEE (Check)
A. IS QUALIFIED FOR 45B. PHYSICAL CATAGORY
B. IS NOT QUALIFIED FOR
47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS
BY ITEM NUMBER A B C E
48. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE
49. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE
50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN(Indicate which) SIGNATURE
51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE
STANDARD FORM 88 (BACK)
NO. OF ATTACHED SHEETS:
MEDICAL RECORD
REPORT OF MEDICAL HISTORY DATE OF EXAM
NOTE: This information is for official and
medically-confidential use only and will not be released to unauthorized
persons
1. NAME OF PATIENT(Last, first, middle)
2. IDENTIFICATION NUMBER 3. GRADE
4a. HOME STREET ADDRESS(Street, City, State,
ZIP)
5. EXAMINING FACILITY
4b. CITY
4c. STATE
4d. ZIP CODE
6. PURPOSE OF EXAMINATION
7. STATEMENT OF PATIENT'S PRESENT HEALTH AND
MEDICATIONS CURRENTLY USED(Use additional pages if necessary)
a. PRESENT HEALTH b. CURRENT MEDICATION REGULAR
OR INTERM.
c. ALLERGIES(Include insect bites/stings and
common foods)
d. HEIGHT e. WEIGHT
8. PATIENT'S OCCUPATION
9. ARE YOU (check one)
RIGHT HANDED LEFT
HANDED
10. PAST/CURRENT MEDICAL HISTORY
CHECK EACH ITEM YES NO DON'T KNOW CHECK EACH
ITEM YES NO DON'T KNOW CHECK EACH ITEM YES NO DON'T KNOW
Household contact with
Shortness of breath
Bone, joint or other deformity
anyone with tuberculosis
Pain or pressure in chest Loss of finger
or toe
Tuberculosis or positive TB test
Chronic cough
Painful or "trick" shoulder
Blood in sputum or when
Palpitation or pounding heart or elbow
coughing
Heart
trouble
Recurrent back pain or any
Excessive bleeding after injury
High or low blood pressure back injury
or dental
work
Cramps in your
legs
"Trick" or locked knee
Suicide attempt or plans
Frequent indigestion
Foot trouble
Sleepwalking
Stomach, liver or intestinal Nerve injury
Wear corrective lenses
Gall bladder trouble or
Paralysis (including infantile)
Eye surgery to correct
vision
gallstones
Epilepsy or seizure
Lack vision in either eye
Jaundice or hepatitis
Car, train, sea or air sickness
Wear a hearing
aid
Broken
bones
Frequent trouble sleeping
Stutter or stammer
Adverse reaction to medicine Depression or excessive
worry
Wear a brace or back
support
Skin
diseases
Loss of memory or amnesia
Scarlet
fever
Tumor, growth, cyst, cancer Nervous trouble of any
sort
Rheumatic
fever
Hernia
Periods of unconsciousness
Swollen or painful joints
Hemorrhoids or rectal disease Parent/sibling with diabetes,
Frequent headaches
Frequent or painful urination
cancer, stroke or heart disease
Dizziness or fainting spells
Bed wetting since age 12 X-ray or other radiation therapy
Eye
trouble
Kidney stone or blood in urine Chemotherapy
Hearing
loss
Sugar or albumin in urine Asbestos or toxic chemical
exposure
Recurrent ear infections
Sexually transmitted diseases
Chronic or frequent colds
Recent gain or loss of weight Plate, pin or rod in any
bone
Dental problems Eating disorder
(anorexia, bulimia, etc...) Easy
fatigability
Sinusitis
Been told to cut down or criticized for alcohol use
Used tobacco
Hay fever or allergic
rhinitis
Arthritis, Rheumatism, or Bursiti Head
injury
Used illegal
substances
Asthma Thyroid trouble or goiter
11. FEMALES ONLY
CHECK EACH ITEM YES NO DON'T
KNOW DATE OF LAST MENSTRUAL PERIOD DATE OF
LAST PAP SMEAR DATE OF LAST MAMMOGRAM
Treated for a female disorder
Change in menstrual pattern
CHECK EACH ITEM. IF "YES' EXPLAIN IN
BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER
ITEM YES NO
12. Have you ever been refused employment
or been unable to hold a job or stay in school because of:
a. Sensitivity to chemicals,
dust, sunlight, etc.
b. Inability to perform certain
motions
c. Other medical reasons (if
yes, give reasons)
13. Have you ever been treated for a mental
condition? (If yes, specify when, where, and give details)
14. Have you ever been denied life insurance?
(If yes, state reason and give details)
15. Have you had, or have you been advised
to have, any operation? (If yes, describe and give age at which occurred)
16. Have you ever been a patient in any type
of hospital? (If yes, specify when, where, why, and name of doctor and
complete address of hospital)
17. Have you consulted or been treated by
clinics, physicians, healers, or other practitioners within the last 5
years for other than minor illnesses? (If yes, give complete address of
doctor, hospital, clinic and details)
18. Have you ever been diagnosed with a learning
disability? (If yes, give type, where and how diagnosed)
19. LIST ALL IMMUNIZATIONS RECEIVED
24a. TYPED OR PRINTED NAME OF EXAMINEE
24b. SIGNATURE 24c. DATE
NOTE: HAND TO DOCTOR OR NURSE, OR IF
MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY".
25. PHYSICIAN'S SUMMARY AND ELABORATION OF
ALL PERTINENT DATA (Physician shall comment on all positive answers in
items 7 through 11. Physician may develop by interview any additional
medical history deemed important, and record any significant findings here.)
26. Have you ever been medically disqualified for any dive or other physical at any time? Y / N
a. If you were disqualified, do you have a waiver? Y / N
27. Since your last physical or in the last 18 months, have you been sick, injured, consulted a Physician, used medication (including over the counter), or been hospitalized for any reason? Y / N
28. Have you ever experienced any middle or inner ear dysfunction including: inability to equalize middle ear pressure, inner or middle ear surgery, ringing, disequilibrium, hearing deficit? Y / N
29. Have you ever been told your uncorrected vision in either eye was worse than 20/20? Y / N
30. Do you have any difficulty distinguishing colors or seeing at night? Y / N
31. Have you ever had any corneal surgery, or manipulation to correct poor vision? Y / N
32. Since age 12, have you had asthma or wheezing at any time? Y / N
33. Have you ever had a pneumothorax, experienced pulmonary barotrauma, had a positive PPD, taken INH in past year, or have history of sarciodosis? Y / N
34. Do you have any skin condition worsened by tight clothing, moisture, or sun exposure? Y / N
35. Have you ever had difficulty breathing from underwater equipment, including a snorkel? Y / N
36. Do you have any musculoskeletal condition that limits intense exercise, suffered any type of fracture in the last 3 months, or had any bone/joint surgery in last 6 months Y / N
37. Have you ever been evaluated for, or treated for, any psychiatric problems, depression, stress, anxiety, nervous breakdown, schizophrenia, mania, psychosis, anorexia, bulimia, binge eating, self-induced vomiting, personality disorder, marital problems, or learning disability? Y / N
38. Have you ever used alcohol to excess resulting in: legal problems to include arrest for driving (DUI/DWI), absence from work or school, loss of job; impairment of health; marital problems; or been diagnosed with dependence or had any level of treatment for abuse? Y / N
39. Have you ever had a migraine or other severe headache? Y / N
40. Have you ever fainted, had vertigo (spinning dizziness), seizures, convulsions, or sustained a head injury resulting in loss of consciousness, loss of memory, concussion, or skull fracture? Y / N
41. Do you have any area of altered sensation or strength in your body? Y / N
42. Have you ever suffered Decompression Sickness or Arterial Gas Embolism? Y / N
43. Do you suffer from motion sickness or fear of enclosed spaces? Y / N
DIVING MEDICAL OFFICER COMMENTS
Adapted from
Guide to Scientific Diving Safety and Navy
Standards
*
Most recently there have been good studies to show that stapedectomy is not the risk that
was once thought. The UKSDMC do not address the issue on their web site.
See this article:
Otolaryngol Head Neck Surg 2001 Oct;125(4):356-60
Diving after stapedectomy: clinical experience
and recommendations.
House JW, Toh EH, Perez A.
Clinical Studies Department, House Ear Clinic
and Institute, 2100 West Third
Street, Los Angeles, CA 90057, USA.
CONCLUSIONS: Stapedectomy does not appear to increase the risk of inner ear barotrauma in scuba and sky divers. These activities may be pursued with relative safety after stapes surgery, provided adequate eustachian tube function has been established.
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