DSD Medical questionnaire
The purpose of the Medical Questionnaire is to find out if you should be examined by a physician before participating in recreational scuba diving. 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 a physician.
Please answer the following questions about your medical situation with a YES or NO. If you think that you have a YES, probably you must consult with a physician. If you are not sure, please contact with us.
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Full Name *
Email *
Date of birth *
MM
/
DD
/
YYYY
Do you currently have an ear infection? *
Do you have a history of ear disease, hearing loss or problems with balance? *
Do you have a history of ear or sinus surgery? *
Are you currently suffering from a cold, congestion, sinusitis or bronchitis? *
Do you have a history of respiratory problems, severe attacks of hayfever or allergies, or lung disease? *
Have you had a collapsed lung (pneumothorax) or history of chest surgery? *
Do you have active asthma or history of emphysema or tuberculosis? *
Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities? *
Do you have behavioral health, mental or psychological problems or a nervous system disorder? *
Are you pregnant? *
Do you have a history of colostomy? *
Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery? *
Do you have a history of high blood pressure, angina, or take medication to control blood pressure? *
Are you over 45 and have a family history of heart attack or stroke? *
Do you have a history of bleeding or other blood disorders? *
Do you have diabetes? *
Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them? *
Do you have a history of back, arm or leg problems following an injury, fracture or surgery? *
 Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)? *
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