PADI padicom MEDICAL STATEMENT @) yy eae Participant Record (Confidential information) Please read carefully before signing. ‘Ths a etatomentin which you are interod ot some poten ks Invted in scuba Giving and the conduct enue of you rng the scuba tanirg pogran. You Sqrature on ths statomar is equed fer ou fo pariopate ir the sata raining program otfred , and $$ ssg¢ locate in te a ty sateprovioe ot ead this statement pio te srig it. You mus complete is Medical Satoront,whchinclodes the reical vestonare secon, 0 ‘wo in he seuta ing progam. Iiyou are a ming, you must have tis Statement signed by pret cr quad. Dirig & an excting ard danandirg acivty. When performed comet, apg cect ecaiques, it isreatvely ste. When Divers Medical Questionnaire “othe Participant: The pase of is Mel Oster ut asa be xa iedy You dao be paatigneoeatond ve rang. Apetre Its eatin dott esa duly ufo eg. Ape feore near atbwresapeontng contra es oa) ‘hl gaya mt eke aves yur pyscan or bgp ‘on ates. ‘axe yube pegrant ora you atenpin econ pera? |e yo pesinty akg peseroton madcaors (vi eeepc ideo eat ral) ‘re youve 45 yeas ct age ann anew YES ee rare ce ‘toning? + caret snow ape, cars eae + hae aig ches ee + fae fly hiro ert atc ese + recent eosin maa care + igh band sire + abebs mous, een conole by Gt be Mave you ever had or do you currently have... Asha, ot onan wihbeatig, or whoring wih aoe? Frequent r severe tacks of haya oaorgy? Frequent cos, snus or tree? ‘ny am ag eas? Preunaborr clap rg)” ter cts ease chest sugin? Baharral heath rental pyetoogea| pales Fane aac, aro hosed pen srs)? peg sts conor ae necator prevent hen? ecurigcompcates iganeheataces or ke eda te reat ben? Bactous rag lal los ot corsosses)? Frequent sv saleig to men sickness sas, cask, ve? stabs safety procedures ar rotfolowed, however there are Inoeased sks. Tosauta ve ste, yeu stoudnet be exterly overwegt or ‘tol conditon. ving can be sverunus under cern cordon. You ‘espiatry and crcl syst must bo n good heath Alby a spécas mabe normal ar heahy. Aprsen with coronary seas, a ‘urent cod or congestion, eplpsy a severe medica problem or who is nde the ntueno of acceler drugs shoul ot dive. yeu have asta hoat dease, other chronic medal coditoes ox yeu ae tk lng maccatons ena requir basis, you shoud cnet your oct: and theirstuctotefoeparicpainginths progan, andor aregla basis thereat upon compiotor. You wills laa from the stor the ‘ngotant salty ules regrtng beating ard equalzatin whe scuba ng. Improper use of scutaequprent can rsuitin sarous jury. ‘You must be rorugtlyinstuced int usa under rec sopanison of quaifedinstueter use it safely Ifyou tave ary aditoral questions regarsing ths Media ‘Statement othe Medal Quostenrare sector, review fem wih your lnsnucto blr signing ease anne tho folowing quests en our past resent medal Noy vita YES orNO. Ifyou ze nct su, anwar ES. any of ese itens sp 12 you wo mst request hat os const wha ayia tr patting n soit dig. Yer sgh you wih en RST Nese Sizenet ‘a hens Rereatral Sasa Der Physal Bannan tae you phys. Dysettey or deykten eqn med itaverton? Any de ascites or teanpresson snes? ‘bio potommodwae arise (narple wal 18kniowmie wi 12 i) ead whos consises ne paste yous? Rerurst bak pba? aco spd sae? Diets? Back, am orig potions flowy suey, iy or fac? igh nd rss or take niet coo bho ress? Heart ones? eat atac? Ana, ber sugar or bod ese sen? Sus irony? a dass orpey, hago pelos wt ais? ezurent ow potlens? ‘Becng ot ohe tod ores? Hera? ces or ow sug Acoli restr? esata ag usec tote, aati ne ast ee yeas? ‘The information| have provided about my medical history is accurate to the best of my knowledge. / agree to accept responsibly for omissions regarding my falure to disclose any existing or past heath condition. Sea ta Seno Reea oe oa‘STUDEN’ Please print legibly. Name = Bim Dae ee aling Adios oy. ‘StaterPrvince Rion County. ‘pPestal Code Ham Phone ( Busines Phene( Enal FAL Name and adress of your family physician Pryscn cnet ats Datel physcal xaninaton Name el examine iio cess Phote( Enal Wore you ever requied to havea physical fer Gvng? C1Yes. C)No to, whan? PHYSICIAN ‘This person aging fr ning otis resort ceri to engage in scuba (st-cortained underter breathing aprarats) ding. You opron of tho apliean’'s madea fines fe scuba ving equistad. There ala qudlres atached fo yeutilomation and ference, Physician's Impression [© Hind no medica conitons tat | conser incompatble wit diving. Dam unable to recommend this individual for ding. Romarks Date ian Si aa Rat HP Dar Physican Clnictospital Addsess Prove( Enal