CONFIDENTIAL February 2005
Any fee in respect of the medical examination is the responsibility of the person being examined.
Diving training must not be undertaken until the candidate has completed a Medical
Declaration or had a Medical Examination confirming fitness to dive
Before anyone can undertake diver training, it is necessary for him or her to have completed this medical declaration. If he or she answers”Yes” to
any question they must contact a medical referee (listed on the last page of this form) which may result in a medical examination. Exceptional
fitness is not essential; both men and women can dive safely providing they are reasonably fit and do not suffer from any of the possible
disqualifying conditions listed in the questionnaire. Sport diving can at times involve heavy physical exertion. Moreover, recreational diving in the
UK is carried out in what can occasionally be a cold, dark and hostile environment and it entails responsibility for the safety of other divers.
A reference table describing the more common medical conditions which may cause problems for divers or may disqualify them from diving
altogether is set out on the inside pages.
If you have to see a Medical Referee and are found fit to dive, they will give you a completed Certificate of Fitness to Dive, You should show it to
your Diving Officer and insert it in your Qualification Record Logbook for reference purposes.
All Divers need to submit a completed medical questionnaire annually. If there are any “yes” responses, the medical referee will decide on fitness
to dive, any change in health must be declared to a referee. Once a “yes” has been cleared as fit to dive and there are no new changes in health, the
medical questionnaire will be passed in subsequent years with no further medical needed. A copy of completed form must be kept by the diver,
his/her Branch and a copy sent to the organisations HQ. The Medical Referee is advised to retain the records of those examined. and give a
photocopy of the record to the diver and send a copy to organisations HQ.

This portion to be completed by the applicant

Dive Organisation………………Branch. .………………………….Postcode. Date of birth.Mem. No.………………. Diver Medical Health Questionnaire
1. Have you suffered at any time from diseases of the heart and 11. Have you ever had any other disease of the brain or circulation including high blood pressure, angina, chest pains nervous system (including strokes or multiple sclerosis)? 2. Have you suffered from or had to take medication for asthma? 12. Have you ever had any back or spinal surgery? 3. Have you at any time had chest or heart surgery? 13. Have you any history of mental or psychological illness of any kind, fear of small spaces, crowds or panic attacks? 4. Have you ever had collapsed lung or pneumothorax? 14. Have you any history of alcohol or drug abuse in the past 5. Have you ever had any other chest or lung disease? 6. Have you suffered at any time from blackouts, fainting or 16. Are you currently taking any prescribed medication 7. Have you had regular ear problems in the past ten years? 17. Are you currently receiving medical care or have you consulted the doctor in the last year other than for trivial 8. Do you have an ileostomy, colostomy or ever had repair of a 18. Have you ever been refused a diving medical certificate or life insurance or been offered special terms? 19. Have you ever had, or been treated for, decompression If you answered “Yes” to any question, then give further details below. The completed form should then be returned to headquarters and they will forward it to a medical referee. I hereby declare that to the best of my knowledge, l am in good general health and declare that I have not omitted any information which might be relevant to my fitness for diving. I authorise any doctor who has attended me to disclose my medical history if requested to by a Medical Referee. Signed_________________________________________________________ Date_________________________________ MEDICAL STANDARDS
These notes are included for the guidance of divers completing this form who may be unfamiliar with requirements for diving. If in doubt, please discuss with your nearest Medical Referee. Should your health change, you must notify your diving organisation and see a Medical Referee. If your instructor is unhappy about any aspect of your health, you may be referred to a Medical Referee. If planning to dive abroad, some countries require a full medical examination. Check in good time before you travel. Diving is not advised during pregnancy or when trying to conceive. Smoking reduces fitness and increases the risk of air embolism, pneumothorax, and coronary thrombosis. DISQUALIFYING FACTORS

Ear clearing is best checked by a practical test chronic vestibular disease in new entrants. Perforated eardrums can be surgically repaired "paper thin" scars. Unilateral nasal block. Sinusitis if not adversely affected by diving Oral Cavity
Dentures must be retained in place on fully opening the mouth and not be Bad teeth and fillings should not normally dislodged by placing jaws together in any position, or by movement of one denture disqualify from diving but dental attention is against the other. They should extend to the muco-buccal fold. If dentures do not recommended as neglect leads to dental caries, satisfy these requirements, they should not be worn whilst diving. Cleft palate not Respiratory System
A chest X-ray is not required on entry or at Tuberculosis scars other than healed primary repeat medical examination unless there is a
history of significant cardiovascular disease, respiratory disease or occupational exposure (since the last medical in the case of a repeat surgical treatment should be discussed with a medical) or if the physical examination reveals pneumothorax that occurred more than four respiratory systems. Doctors must see film or years ago may be allowable provided a full set of lung function tests are performed and are normal. A Medical Referee must be consulted. Cardiovascular System
Subjects with a pacemaker must be seen by a disease), significant valve disease. Other heart disease, systolic pressure over 160 mm Hg, diastolic pressure over 100 mm Hg in entrants, or other evidence of hypertensive Intracardiac shunts (“Holes in the heart”) must be seen by a Medical Referee. Haematology
Haemophilia if factor VIII is below 20%, Sickle cell test only where clinically indicated. polycythaemia are not allowed to dive except provided factor VIII is more than 20% but only Subjects with sickle cell trait should exercise caution when using rebreathers owing to the risks associated with mild degrees of hypoxia. Polycythaemia if haematocrit normal with treatment. Abdomen and
Significant proteinuria (albumin in the urine), Urogenital System
Nervous System and
History of confirmed epilepsy including post- A single isolated fit or severe head injury to be impairment to be reported to Referee. A long Any serious head injury in past three months. fit free period off anticonvulsants may be personality disorders. Any disease of CNS (MS, Polio, Petit Mal, etc.) to be seen by Medical Referee. Endocrine
An annual medical is mandatory for diabetics. The use of the following disqualifies: oral sympathomimetics (other than proprietary tranquillisers, sedatives and hypnotics) has been nasal decongestants), oral steroids, muscle used, the candidate should not dive for at least 3 relaxants, digoxin, and psychotropic drugs - months after complete cessation of therapy without the consent of a Medical Referee. Alcohol, drug or narcotic abuse to disqualify. Decompression illness
since last Medical
Anyone with a significant disability must be assessed by a Medical Referee. Suitable organisations to contact are "Dolphin" (Tel No 01752 209999) or the Headquarters of the Diving Associations who have jointly published this form.


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