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.
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.