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Medical Statement Participant Record ... - Scuba Center

The information I have provided about my Medical history is accurate to the best of my knowledge. I affirm it is my responsibility to inform my instructor of any and all changes to my Medical history at any time during my participation in Scuba programs. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition, or any changes 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 are currently receiving Medical care have a high cholesterol level high blood pressure have a family history of heart attack or stroke diabetes mellitus, even if controlled by diet aloneHave you ever had or do you currently Asthma, or wheezing with breathing, or wheezing with exercise?

in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program. In addition, if your medical condition changes at any time during your scuba programs it is …

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