Medical Questionnaire iDiveBCN

Medical questionnaire

"*" indicates required fields

Name*

Surname*

Birthday

DD slash MM slash YYYY

Phone*

Form response date*

DD dash MM dash YYYY

1 - I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance(If the answer is yes, answer questions A)*

Yes

2 - I am over 45 years of age.(If the answer is yes, answer questions B)**

Yes

3 - I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.**

Yes

4 - I have had problems with my eyes, ears, or nasal passages/sinuses. (If the answer is yes, answer questions C)* *

Yes

5 - I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.**

Yes

6 - I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.(If the answer is yes, answer questions D)**

Yes

7 - I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.(If the answer is yes, answer questions E)*

Yes

8 - I have had back problems, hernia, ulcers, or diabetes.(If the answer is yes, answer questions F)*

Yes

9 - I have had stomach or intestine problems, including recent diarrhea.(If the answer is yes, answer questions G)*

Yes

10 - I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*

Yes

Section A

A1 - Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*

Yes

A2 - Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*

Yes

A3 - A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*

Yes

A4 - Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*

Yes

A5 - Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*

Yes

Section B

B1 - I currently smoke or inhale nicotine by other means.*

Yes

B2 - I have a high cholesterol level.*

Yes

B3 - I have high blood pressure.*

Yes

B4 - I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*

Yes

Section C

C1 - Sinus surgery within the last 6 months.*

Yes

C2 - Ear disease or ear surgery, hearing loss, or problems with balance.*

Yes

C3 - Recurrent sinusitis within the past 12 months.*

Yes

C4 - Eye surgery within the past 3 months.*

Yes

Section D

D1 - Head injury with loss of consciousness within the past 5 years.*

Yes

D2 - Persistent neurologic injury or disease.*

Yes

D3 - Recurring migraine headaches within the past 12 months, or take medications to prevent them.*

Yes

D4 - Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*

Yes

D5 - Epilepsy, seizures, or convulsions, OR take medications to prevent them.*

Yes

Section E

E1 - Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*

Yes

E2 - Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*

Yes

E3 - Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*

Yes

E4 - An addiction to drugs or alcohol requiring treatment within the last 5 years.*

Yes

Section F

F1 - Recurrent back problems in the last 6 months that limit my everyday activity.*

Yes

F2 - Back or spinal surgery within the last 12 months.*

Yes

F3 - Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.*

Yes

F4 - An uncorrected hernia that limits my physical abilities.*

Yes

F5 - Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*

Yes

Section G

G1 - Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*

Yes

G2 - Dehydration requiring medical intervention within the last 7 days.*

Yes

G3 - Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*

Yes

G4 - Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*

Yes

G5 - Active or uncontrolled ulcerative colitis or Crohn’s disease.*

Yes

G6 - Bariatric surgery within the last 12 months.*

Yes

Acceptance of the declaration

If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to thestatement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’sEvaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.*

I accept that I have answered YES to any of the previous questions Download the medical questionnaire

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions*

I have read and accept the participant's declaration

Signature*

Name

Family name

Phone Number

Date

1 - I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.

Yes No

2 - I am over 45 years of age.(If the answer is yes, answer questions B)

Yes No

4 - I have had problems with my eyes, ears, or nasal passages/sinuses.(If the answer is yes, answer questions C)

Yes No

5 - I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes No

6 - I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.(If the answer is yes, answer questions D)

Yes No

8 - I have had back problems, hernia, ulcers, or diabetes.(If the answer is yes, answer questions F)

Yes No

9 - I have had stomach or intestine problems, including recent diarrhea.(If the answer is yes, answer questions G)

Yes No

10 - I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).

Yes No

A1 - Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).

Yes No

A2 - Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.

Yes No

A4 - Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.

Yes No

A5 - A diagnosis of COVID-19.

Yes No

B1 - I currently smoke or inhale nicotine by other means.

Yes No

B2 - I have a high cholesterol level.

Yes No

B3 - I have high blood pressure.

Yes No

C1 - Sinus surgery within the last 6 months.

Yes No

C2 - Ear disease or ear surgery, hearing loss, or problems with balance.

Yes No

C3 - Recurrent sinusitis within the past 12 months.

Yes No

C4 - Eye surgery within the past 3 months.

Yes No

D1 - Head injury with loss of consciousness within the past 5 years.

Yes No

D2 - Persistent neurologic injury or disease.

Yes No

D3 - Recurring migraine headaches within the past 12 months, or take medications to prevent them.

Yes No

D4 - Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.

Yes No

D5 - Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Yes No

E1 - Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Yes No

E2 - Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.

Yes No

E3 - Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.

Yes No

E4 - An addiction to drugs or alcohol requiring treatment within the last 5 years.

Yes No

F1 - Recurrent back problems in the last 6 months that limit my everyday activity.

Yes No

F2 - Back or spinal surgery within the last 12 months.

Yes No

F3 - Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.

Yes No

F4 - An uncorrected hernia that limits my physical abilities.

Yes No

F5 - Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Yes No

G1 - Ostomy surgery and do not have medical clearance to swim or engage in physical activity.

Yes No

G2 - Dehydration requiring medical intervention within the last 7 days.

Yes No

G3 - Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.

Yes No

G4 - Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).

Yes No

G5 - Active or uncontrolled ulcerative colitis or Crohn’s disease.

Yes No

G6 - Bariatric surgery within the last 12 months.

Yes No

I have read and accept the participant's declaration

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