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. 

Please answer the following questions on your medical history
with a YES or NO.  If you are not sure, answer YES.  If any of the items below apply to you then your physician is required to
complete the physician statement on Page 2 of the "Medical Statement" form.

Dysentery or dehydration requiring medical intervention?
Any dive accidents or decompression sickness?
Could you be pregnant, or are you attempting to become pregnant?
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
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?
Head injury with loss of consciousness in the past five years?
Recurrent back problems?
Back or spinal surgery?
Diabetes?
Have a family history of heart attack or stroke?
Back, arm or leg problems following surgery, injury or fracture?
Are currently receiving medical care?
High blood pressure or take medicine to control blood pressure?
High blood pressure?
Heart disease?
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?
Heart attack?
Angina, heart surgery or blood vessel surgery?​
Sinus surgery?
Ear disease or surgery, hearing loss or problems with balance?
Frequent or severe attacks of hayfever or allergy?
Recurrent ear problems?
Frequent colds, sinusitis or bronchitis?
Bleeding or other blood disorders?
Any form of lung disease?
Hernia?
Pneumothorax (collapsed lung)?
Ulcers or ulcer surgery?
Other chest disease or chest surgery?
​ Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
A colostomy or ileostomy?
Recreational drug use or treatment for, or alcoholism in the past five years?
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.)?

The information I have provided about my medical history is accurate to the best of my knowledge.I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.

Your Signature - use your mouse or finger to write

Signature of a Parent or Guardian

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