DiverMojo Medical Self Assessment

Please read carefully before signing.

Complete this self assessment. IF you answer 'yes' to any of the questions you are required to have your physician complete the physician statement on Page 2 of the "Medical Statement" form.
 

The purpose of this Medical Self-Assessment is to find out if you should be examined by your doctor before participating in recreational diver training.  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 your physician prior to engaging in dive activities. 

Could you be pregnant, or are you attempting to become pregnant?
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)
Are you over 45 years of age and can answer YES to one or more of the following: Currently smoke a pipe, cigars or cigarettes?
Have a high cholestorol level?
Have a family history of heart attack or stroke?
Are currently receiving medical care?
High blood pressure?
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)
Diabetes mellitus, even if controlled by diet alone?
Have you ever had or do you currently have: Asthma, or wheezing with breathing, or wheezing with exercise?
Frequent or severe attacks of hayfever or allergy?
Frequent colds, sinusitis or bronchitis?
Any form of lung disease?
Pneumothorax (collapsed lung)?
Other chest disease or chest surgery?
​ Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
Epilepsy, seizures, convulsions or take medications to prevent them?
Recurring complicated migraine headaches or take medications to prevent them?
Blackouts or fainting (full/partial loss of consciousness)?
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?

DiverMojo LLC

2841 N Ocean Blvd, Suite 1706, 
Fort Lauderdale, Florida, 33308 
United States 

+1 919-697-5837

© 2020  DiverMojo LLC — All Rights Reserved 

Florida Seller of Travel Ref. No. ST41857