DIVERS MEDICAL CERTIFICATE

FULL NAME: …………………………………………………………………………

ADDRESS:………………………………………………………………………………………

                                    ………………………………………………………………………………………

DATE:  ……………./……………./……………..

This is to certify that the above mentioned has been fully examined by me this day.

1.        He/she has been found to be fit for diving

Advice to instructor (where relevant)

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

2.         He/she is permanently unfit for diving

He/she should undergo a routine medical review in ………….. years

Signed…………………………………………………………………………………….

Medical Practitioner………………………………………………………………………….

Address …………………………………………………………………………………….

Phone number ……………………………………

DIVERS MEDICAL EXAMINATION (SPORT DIVING)

Revised 1987 in conjunction with the South Pacific Underwater Medical Society, (NZ).

SECTION A:   (diving candidate to complete prior to medical examination)

Full Name:………………………………………………………………………………………..

Address:………………………………………………………………………………………..

……………………………………………………………………………………..

Phone Number: …………………………………………

Date of Birth: ……………/……………/…………….     Age:.........................       

Occupation:  ……………………………………........................…...

 

 

Have you ever suffered from:

 
YES
NO
NOTES
 shortness of breathe      
asthma      
any other lung condition      
nose or sinus disease      
ruptured ear drum or ear surgery      
dizziness fainting or blackouts      
fits or epilepsy      
concussion or head injury      
diabetes      
any other illness or disability      
any other operation or injury      
any heart complaint       
chest pain      

 

 

 

 

 

 

 

 

 

 

1.         Do you smoke? YES/NO……………….    Number per day  ………………………

2.         Are you on any medication?    YES/NO        ……………………………………………………………………….

3.         Any know allergies?  YES/NO                ……………………………………………………………………….

4.         Have you ever failed a medical exam?  YES/NO............................................. 

  Normal Y/N or describe abnormalities
Cardiovascular    
Respitory system    
Effort tolerance    
External, middle, inner ear    
Eustachian tube patency    
Mouth and teeth    
Abdomen    
Nervous system    
Locomotor system    
Identification marks    

 

 

 

 

 

 

 

 

Notes: I hereby certify that the above information is correct, and authorise release of the attached certificate to my diving instructor.  Where appropriate, further medical information may be released to PADI New Zealand’s Medical Advisor.

SECTION B:  (Medical Practitioner to complete)

Examination date:                   ………/………../…………

Height:                                  …………………………… cm

Weight                                 …………………………….kg

BP                                      …………/…………mmHg    PEFR………………L/m

                       

Further notes:                      …………………………………………………………………………

  …………………………………………………………………………

THE FOLLOWING INVESTIGATIONS MAY BE INDICATED IN SOME CANDIDATES

                                               

                                                            Date         Result

1.         Chest X-ray                             …/…/…… …………………………………………..

2.         Pulmonary function                 …/…/………………………………………………..

3.         ECG                                        …/…/……… ………………………………………..

4.         Exercise ECG                       …/…/……… ………………………………………..

5.         Audiogram                            …/…/……… ………………………………………..

6.         Urinalysis                              …/…/……… ………………………………………..

7.         Other                                    .…/…/………  ………………………………………

Instructions to Medical Practitioner:

Complete the medical certificate and hand to candidate.  Record certification details below.

RECORD OF CERTIFICATION ISSUED:

(circle)             FIT

                       UNFIT      

Advice to instructor:            ………………………………………..

                                                            ………………………………………………………………..

                        Re-examine in  …………..  years

………………………………………………….

Signed

 

DIVING MEDICAL -  Guide to Medical Examiner

  1. Diving frequently involves heavy sustained effort, often without opportunity to rest.  The diving gear is heavy and awkward to lift and carry on land or boat.  Special attention should therefore be paid to the cardiovascular and respiratory systems.
  2. All air containing spaces must equalise pressure readily.  Special attention should be paid to equalising middle ear pressure (Valsalva manoeuvre), and obstructive lung disease (eg history of asthma).
  3. Even momentary impairment of consciousness under water may result in death (eg epilepsy).
  4. The following are contraindications to diving:

a) Epilepsy

b) Insulin treated diabetes
c) Asthma
d) History of spontaneous pneumothorax
e) Ischaemic hear disease
f) Pregnancy
  1. Other medical conditions which may require special consideration are:  previous middle ear or lung surgery, hypertension, impaired lung function, severe migraine, sever motion sickness, psychological disorders, physical handicaps, visual or hearing impairment, obesity, heavy smoking, drug or alcohol use and advancing age.
  2. Some medical conditions (eg recent chest or ear infection, trauma etc) may render an applicant temporarily unfit  to dive, and will require reassessment at some later date.

Should there be any doubt as to the suitability of a diving applicant please contact PADI Asia/Pacific to be directed to further medical advice.

Ph              0800 664440 Note They are based in Sydney and work to Australia time.