HEALTH QUESTIONNAIRE - Revolution Dive

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DESCUBRE
CURSOS DE BUCEO
SNORKEL
INMERSIONES
TARIFAS
RESERVA YA

DESCUBRE
CURSOS DE BUCEO
SNORKEL
INMERSIONES
TARIFAS
RESERVA YA

[vc_row][vc_column][trx_title color=»#1e73be»]QUESTIONNAIRE ABOUT THE HEALTH STATE FOR RECREATIONAL DIVING PRACTICE[/trx_title][vc_column_text]Diving requires good physical and mental health. There are some medical conditions that can be dangerous during diving. They are listed below. If you have OR you are predisposed to any of these conditions, you must be evaluated by a doctor. This Questionnaire of diver’s Doctor provides a basis for determining whether you should seek such an evaluation. If you have any concerns about your physical condition for diving not listed on this form, consult your doctor before diving. References to «diving» on this form cover self-contained recreational diving and freediving. This form is primarily designed as an initial medical examination for new divers, but is also appropriate for divers who are doing continuing education. For your safety and the safety for people diving with you answer all questions honestly.

INSTRUCTIONS: Complete this questionnaire as a prerequisite for freediving or diving with Scuba equipment. Note for women: If you are pregnant, or trying to become pregnant, do not dive.[/vc_column_text]

Name and surname

1. I had problems with my lounges, respiration, hearth or blood. *

Yes, go to question A
No

2. I am over 45 years old. *

Yes, go to question B
No

3. I have problems doing moderate exercises (e.g.walking 1,6 kilometres in 12 minutes or swimming 200 metres without getting tired), or I couldn't participate in a normal fisical activity because of fisical health reasons within the last 12 month. *

Yes *
No

4. I had problems with my eyes, ears, or fosas nostrils or paranasal sinuses. *

Yes, go to question C
No

5. I had surgery a in the last 12 months, or have ongoing problems related to previous surgery.

Yes *
No

6.I have lost consciousness, have had migraine headaches, seizures, stroke, significant head injury, or have suffered from persistent neurological illness or injury. *

Yes, go to question D
No

7. I had psychological problems, I was diagnosed with a learning disability, personality disorder, panic attacks, or an addiction to drugs or alcohol. *

Yes, go to question E
No

8. I had back problems, hernia, ulcers or diabetes *

Yes, go to question F
No

9. I have had stomach or intestinal problems, including recent diarrhea. *

Yes, go to question G
No

10. I am taking prescription medications (with the exception of contraceptives or antimalarial drugs). *

Yes *
No

A - I have/have had: Thoracic surgery, cardiac surgery, stenting or phneumothorax (collapsed lung). Asthma, wheezing, severe allergies, hayfever, or congested airways in the past 12 months that limits my physical activity or exercise. A problem or disease involving my hearth such as: angina, chest pain on exertion, hearth failure, pulmonary edema, cardiomyopathy, or stroke, or I am taking medication for any hearth condition. Recurrent bronchitis and persistent cough in the past 12 months, or have been diagnosed with emphysema.

Yes *
No

B - I am over 45 years old and: I currently smoke or inhale by other means. I have a high cholesterol level. I have high blood pressure. I have had a family member (1st or 2nd degree inbreeding) who died of sudden death or heart disease or stroke before age 50, or I have a family history of heart disease before age 50 (including abnormal heart rythms, coronary artery disease or cardiomyopathy).

Yes *
No

C - I have/have had: Sinus surgery in the last 6 months. Ear disease or ear surgery, hearing loss, or balance disturbances. Recurrent sinusitis in the last 12 months. Eye surgery in the last 3 months.

Yes *
No

D - I have/have had: Head injury with loss of consciousness in the past 5 years. Persistent neurological injuries or illnesses. Recurring migraine headaches in the past 12 months, or taking medications to prevent them. Fainting or fainting (total/ partial loss of consciousness) in the past 5 years. Epilepsy, seizures or convulsions, or taking medications to prevent them.

Yes *
No

E - I have/have had: Behavioral health, mental or psychological problems that require medical or psychiatric treatment Major depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder requiring psychiatric medication / treatment. I have been diagnosed with a mental health condition or a learning or developmental disorder that requires continued attention. An addiction to drugs or alcohol that requires treatment in the last 5 years.

Yes *
No

F - I have/have had: Recurring back problems in the last 6 months that limit my daily activity. Back or spinal surgery in the last 12 months. Diabetes, whether controlled by insulin or diet, or gestational diabetes in the past 12 months. An uncorrected hernia that limits my physical abilities. Active or untreated ulcers, problem wounds, or ulcer surgery in the past 6 months.

Yes *
No

G - I have: Ostomy surgery and I do not have medical authorization to swim or participate in physical activity. Dehydration that requires medical intervention in the last 7 days. Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months. Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). Active or uncontrolled ulcerative colitis or Crohn's disease. Bariatric surgery in the last 12 months.

Yes *
No

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any question that I may have answered inaccurately or for failure to disclose any existing or past health conditions. *

Yes

Email

[vc_column_text css=».vc_custom_1596703513867{margin-bottom: 20px !important;}»]* If you answered Yes to questions 3,5 or 10 or any of the questions A, B, C, D, E, F or G, take the Medical evaluation form, from the divecentres doctor, provided at the Diving Center, for a medical evaluation. Participation in a diving training program, requires the evaluation and approval of this doctor.[/vc_column_text][/vc_column][/vc_row]

CONTACTA CON NOSOTROS

Nombre *

Nombre

Apellidos

Email *

Mensaje *

Message

Revolution Dive Benidorm
Puerto Comercial Benidorm
Paseo de Colón, 1 - Caseta 3
03501 Benidorm (Alicante)
Teléfono: 618 406 991 - 722 482 828
Email: reservas@revolutiondive.com

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