BS-AC Premier School No137
Island Divers Tenerife

Dive Tenerife With Island Divers
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ISLAND DIVERS MEDICAL STATEMENT PLEASE PRINT
BS-AC PADI Tenerife
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Phone the UK office:
Tel/Fax: 01737 557515

E-mail Us On:
holidays@ultimate17
.freeserve.co.uk

or to E-mail TENERIFE:
info@islanddivers.org

For addresses see:
Where to Find Us.

    

ISLAND DIVERS MEDICAL HISTORY STATEMENT

PLEASE ANSWER THE FOLLOWING QUESTIONS ON YOUR PAST AND 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 YOUR DOCTOR PRIOR TO PARTICIPATING IN SCUBA DIVING

Could you be pregnant or are attempting to become pregnant ?                

Do you regularly take prescription or non-prescription medications ?         YES      NO
Are you over 45 years of age and have 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 strokes                                                 

Have you ever had or do you currently have..

  • Asthma.wheezing with breathing, or wheezing with exercise ?                              
  • Frequent or severe attacks of hay fever or allergy ?                                            
  • Frequent sinusitis or bronchitis ?                                                                        
  • Any form of lung disease ?   
  • Pneumothorax (collapsed lung) ?
  • History of chest surgery ?
  • Claustrophobia or agoraphobia ( fear of closed spaces ) ?
  • Epilepsy, seizures, convulsions or take medications to prevent them  ?
  • Recurring migraine headaches or take medications to prevent them ?
  • History of blackouts or feinting ?
  • History of diving accidents or decompression illness ?
  • History of back problems or surgery ?
  • History of diabetes ?
  • Inability to perform moderate exercise ?
  • History of high blood pressure or take medicine to control it ?
  • History of heart disease ?
  • History of heart attacks ?
  • History of Angina or heart surgery or blood vessel surgery ?
  • History of ear disorders or problem with balance ?
  • History of problems equalising ( popping ) ears with airline travel ?
  • History of bleeding or other blood disorders ?
  • History of any type of hernia ?
  • History of ulcers or ulcer surgery ?
  • History of colostomy ?
  • History of drug or alcohol abuse ?
                        
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