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Medical Standards for Sport Diving


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.

  • Medical evaluation shall be completed:
  •  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.
  • Content of Medical Evaluations
    Medical examinations conducted initially and at the intervals specified above shall consist of the following:
  •  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)
  •  Suggested  Requirements for Diving Medical Examination:
  • Initial examination and first examination over age forty:
  • Medical History
    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.
  •  Periodic re-examination (every 3 years under 40, every 2 years over 40):
  • Medical History
    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)
    divedoctor@medscape.com

    GUIDELINES FOR PHYSICIANS - Medical Fitness to Dive

    PADI Medical Statement
    Physical Exam Form

    References

  • Doc's Diving Medicine Home Page
  • Scubamed
  • Scuba Diving Explained
  • Articles on Diving Medicine
  • Diving Diseases Research Center
  • Diving Medicine Publications
  • Diving Doc Column
  • Aviation / Aerospace Medicine articles and publications
  • The Undersea and Hyperbaric Medical Society
  • Divers Alert Network


  • 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 ____________________________________________
     



     


    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)

                               1 - A          21 - B          41 - A          61 - B
                               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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