Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can
be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by
a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If
you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you
are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in
dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving.
This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing
education. For your safety, and that of others who may dive with you, answer all questions honestly.
Directions
Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.
Yes □ No □
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.
Go to Box A
Yes □ No □
2. I am over 45 years of age.
Go to Box B
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200
meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness Yes □* No □
or health reasons within the past 12 months.
Yes □ No □
4. I have had problems with my eyes, ears, or nasal passages/sinuses.
Go to Box C

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. Yes □* No □
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from Yes □ No □
persistent neurologic injury or disease. Go to Box D
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological
Yes □ No □
problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed
with a learning disability. Go to Box E

Yes □ No □
8. I have had back problems, hernia, ulcers, or diabetes.
Go to Box F
Yes □ No □
9. I have had stomach or intestine problems, including recent diarrhea.
Go to Box G
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than
Yes □* No □
mefloquine/Lariam).

Participant Signature
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant
statement below by signing and dating it.
Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any
consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or
past health conditions.

Participant Signature (or, if a minor, participant‘s parent/guardian signature required.) Date (dd/mm/yyyy)

Participant Name (Print) Birthdate (dd/mm/yyyy)

Instructor Name (Print) Facility Name (Print)

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to
the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire
and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course
requires your physician’s approval.
1 of 3
Participant Name Birthdate
(Print) Date (dd/mm/yyyy)

Diver Medical | Participant Questionnaire Continued

Box A – I have/have had:
Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung). Yes □* No □
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise. Yes □* No □
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or
Yes □* No □
stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. Yes □* No □
A diagnosis of COVID-19. Yes □* No □

Box B – I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means. Yes □* No □
I have a high cholesterol level. Yes □* No □
I have high blood pressure. Yes □* No □
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart
Yes □* No □
disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C – I have/have had:

Sinus surgery within the last 6 months. Yes □* No □
Ear disease or ear surgery, hearing loss, or problems with balance. Yes □* No □
Recurrent sinusitis within the past 12 months. Yes □* No □
Eye surgery within the past 3 months. Yes □* No □

Box D – I have/have had:

Head injury with loss of consciousness within the past 5 years. Yes □* No □
Persistent neurologic injury or disease. Yes □* No □
Recurring migraine headaches within the past 12 months, or take medications to prevent them. Yes □* No □
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. Yes □* No □
Epilepsy, seizures, or convulsions, OR take medications to prevent them. Yes □* No □

Box E – I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. Yes □* No □
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. Yes □* No □
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care. Yes □* No □
An addiction to drugs or alcohol requiring treatment within the last 5 years. Yes □* No □

Box F – I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity. Yes □* No □
Back or spinal surgery within the last 12 months. Yes □* No □
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months. Yes □* No □
An uncorrected hernia that limits my physical abilities. Yes □* No □
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. Yes □* No □

Box G – I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. Yes □* No □
Dehydration requiring medical intervention within the last 7 days. Yes □* No □
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. Yes □* No □
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). Yes □* No □
Active or uncontrolled ulcerative colitis or Crohn’s disease. Yes □* No □
Bariatric surgery within the last 12 months. Yes □* No □
*Physician’s medical evaluation required (see page 1). 2 of 3
Diver Medical | Physician‘s Evaluation Form

Participant Name Birthdate

(Print) Date (dd/mm/yyyy)

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba
diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they
relate to diving. Review the areas relevant to your patient as part of your evaluation.

Evaluation Result
 Approved – I find no conditions that I consider incompatible with recreational scuba diving or freediving.

 Not approved – I find conditions that I consider incompatible with recreational scuba diving or freediving.

Physican‘s Signature Date (dd/mm/yyyy)

Physician’s Name Specialty

(Print)

Clinic/Hospital

Address

Phone Email

Physician/Clinic Stamp (optional)

Created by the Diver Medical Screen Committee in association with the following bodies:
The Undersea & Hyperbaric Medical Society
DAN (US)
DAN Europe
Hyperbaric Medicine Division, University of California, San Diego

2020 3 of 3 10346
Revised 9 July 202
 HAVELOCK DIVE CLUB
GOVIND NAGAR, SWARAJ DWEEP, SOUTH ANDAMAN-744211
CUSTOMER REGISTRATION FORM
FULL NAME GENDER

DATE OF BIRTH AGE

NATIONALITY IDENTIFICATION NO. (ID/PASSPORT)

STREET OR PO BOX MAILING ADDRESS

CITY/STATE ZIP/POSTAL CODE/COUNTRY:

EMERGENCY CONTACT NAME
PHONE NUMBER
E-MAIL ADDRESS
PHONE NUMBER

ASSUMPTION OF RISK LIABILITY RELEASE & HOLD HARMLESS AGREEMENT

THIS IS AN IMPORTANT AGREEMENT, PLEASE READ IT CAREFULLY BEFORE SIGNING.

I hereby affirm that I am aware that free diving In consideration of the services of Havelock Dive
and scuba diving (“activities covered by this Club and/ or any of its affiliates and/or
Release”) are inherently dangerous activities that subsidiary entities, their agents, owners, officers,
can cause permanent injury or death, even when volunteers, employees, participants, contractors,
done properly, cautiously and safely. subcontractors, service providers, designers,
instructors, and all other persons acting in any
I understand that diving with compressed air capacity on their behalf, the manufacturers of
involves certain inherent risks; including but not equipment utilized for the activities covered by
limited to decompression sickness, embolism, this Release, and any other landowners, property
oxygen toxicity, inert gas narcosis or other owners, tenants and sponsors connected with the
hyperbaric/ air expansion injuries that require activities covered by this Release (hereinafter
treatment in a re compression chamber. I still collectively referred to as “Havelock Dive Club”,
choose to proceed with such instructional dives on behalf of myself, my family, representatives,
in-spite of the possible unavailability of a re estate, heirs, assigns, successors and executors, I
compression chamber in proximity to the location hereby unconditionally agree as follows:
in which I shall carryout the activities covered by
this Release, the Havelock Dive Club training
facility.
RELEASE OF LIABILITY

I hereby fully RELEASE AND DISCHARGE my instructor(s), Havelock Dive Club, the from any liability, claims, demands or
causes of action whatsoever arising out of any damage, loss or injury or damages (whether bodily or emotional), or my
property, or my disfigurement, paralysis or death, while preparing to participate and/or participating in any of the
activities covered by this Release, whether resulting from the negligence or other fault, act or omission, either active or
passive, direct or indirect, of any party, including Havelock Dive Club, or from any other cause. Should I observe any
significant hazards during my presence or participation in the activities covered by this Release, I will remove myself
 from the activity and notify the nearest official immediately.

ASSUMPTION OF RISK

I understand, acknowledge and accept that my participation in the activities covered by this Release entails certain
known and unanticipated risks and dangers that cannot be foreseen. I understand that these risks include, but are not
limited to: equipment malfunction or failure to function; defective
or negligent design or manufacture of equipment; improper or negligent operation, maintenance or use of
equipment; carelessness or negligence of instructors and equipment operators; falling on or being impacted by
other participants; slippery or wet equipment; impacting the ground and/or apparatus and/or pool props and/or
associated mechanical structures; displaced safety equipment; general slips/trips/falls or painful crashes while using
any of the equipment or the premises at large; operating out of control or beyond my or another participants’ limits;
the negligence of other
visitors who may be present; participants giving or following inappropriate advice; and my own negligence or
inexperience. I voluntarily, freely, expressly and unconditionally choose to assume all of the risks associated with the
activities covered by this Release, including but not limited to, all risks set out
in this paragraph, and expressly understand that those risks may include bodily, emotional, mental, and personal injury,
illness, heart attack, panic, hyperventilation, drowning, shallow water blackout or other forms of unconscious response,
fatigue, exhaustion, decompression sickness, embolism, oxygen toxicity, narcosis induced disorientation, hyperbaric/air
expansion injury, ear/ear drum injury/rupture as well related traumatic injuries, sinus injury, damage, loss, damage to
property, disability, disfigurement, paralysis or death to myself or to third parties. I understand all time spent in an
underwater dry habitat is under pressure and is the same as time spent underwater. I understand that diving within an
overhead area prevents my direct ascent to the surface and that I undertake such risks voluntarily and on my own
volition. I understand that different breathing gasses have different depth limits and that I will be fully informed and
trained before undertaking use of any breathing gas and that I will personally analyze these gasses and honor all depth
limits therein associated. I voluntarily and freely choose to assume such risks and take all responsibility in respect of
such risks, whether or not described above, no matter what the circumstances of the accident and/or injury.

AGREEMENT NOT TO SUE

I agree never, at any time now or in the future, to institute any lawsuit or cause of action against Havelock Dive Club or
anyone else claiming on my behalf, or initiate or to assist in the prosecution of any claim for damages in respect of
injury to person or property, or my death, or any other loss or damage howsoever occasioned arising from the activities
covered by this Release, whether caused by the act, omission, negligence or fault, active or passive, direct or indirect or
from any other cause, in any jurisdiction including without limitation any court in India.

1. PHYSICAL CONDITION

I confirm that I have read, understood and completed the Medical Statement to the best of my knowledge. I certify
that I am fully aware of my own physical limitations and have not been advised by a qualified medical professional
not to participate in the activities covered by this Release and/ or activities of a similar nature. I warrant that I do
not suffer from any medical condition(s) or health-related problem(s) that preclude participation in the activities
covered by this Release or which may result in me potentially being in a position of risk. I have not taken any
alcoholic beverages, drugs, medicines or substances within the last 12 (twelve) hours which may impair my motor and
visual skill, or cause any other impairment. I will avoid
traveling to a high altitude for at least 24 (twenty-four) hours after participating in the activities covered by this
Release, including avoiding sky diving, undertaking air travel and/or ascending to a high altitude floor of a high-rise
building. I confirm that I am physically fit and capable of undertaking the activities covered by this Release. Havelock
Dive Club will not make an evaluation or recommendation as to my physical limitations, and I will not construe any
statement or action by Havelock Dive Club as an evaluation of, or a recommendation as to, my physical limitations, with
respect to whether I am physically fit to participate in the activities covered in this Release. I agree to abide by the
decision of Havelock Dive Club’s official or agent regarding my participation in the activities covered by this Release.
It is my responsibility to immediately advise a member of staff of any condition that may occur to me and that I will
immediately cease further participation in the activity. I irrevocably authorize that efforts be made to secure medical
treatment for me and consent to all medical treatments and invasive procedures necessary or convenient in order to
cure, stabilize or protect my life and well being.

I personally guarantee the payment of any cost or expense related to my medical treatment and/or the medical
treatment of any person injured as a result of my participation in the activities covered by this Release.

2 WAIVER OF CLAIMS AND INDEMNITY

I understand that by signing this Release, I voluntarily release, forever discharge and agree to indemnify and hold
harmless Havelock Dive Club from and against any and all liabilities, claims, losses, demands, or causes of action, or
proceedings of any kind and character, which are in any way connected with my participation in the activities covered
by this Release, including such claims that allege negligent acts or omissions of Havelock Dive Club. Should Havelock
Dive Club or anyone acting on their behalf, be required to incur attorney’s costs and fees to enforce this Release, I
agree to indemnify and hold harmless for all such fees and costs. I additionally agree to indemnify Havelock Dive Club
against any legal cost, medical cost and any other expense arising from any and all injuries, liabilities or damages from
my participation in the activities covered by this Release.

WAIVER OF RIGHTS
 I understand that by signing this Release, I am giving up important legal rights, and it is my intent to do so and I do so
of my own free will and with full acknowledgement of, and agreement to, the terms and conditions in this Release.

3 TRAINING

I understand that prior to participating in the activities covered by this Release, I shall receive a safety briefing. I warrant
the thoroughness and completeness of any training and/or briefing I receive by voluntarily participating in the activities
covered by this Release. I agree not to manipulate or interfere in any way with the infrastructure or equipment used in
the activities covered by this Release including, but not limited to, underwater cameras, speakers and lighting systems,
cabling and related fixtures, mechanical infrastructure, underwater habitats at 21m and 6m, and inappropriate
disassembly of diving equipment, and I shall obey the instructions and safety warnings issued by Havelock Dive Club at
all times.

4 ENTIRE AGREEMENT

I understand this Release contains the entire understanding and undertaking by me in respect of the activities covered
by this Release and the terms of this Release are contractual and not a mere recital and that Havelock Dive Club is
entitled to rely on this Release for its benefit. I confirm that I am of lawful age and legally competent to sign this
Release. I understand that this Release can and will be used in court, and that agreements like this one have been
upheld by courts in similar circumstances. I further agree that if any provision of this Release is found to be
unenforceable or invalid, that provision shall be severed from this Release. The remainder of this Release will then be
construed as though the unenforceable provision had never been contained herein.

5 WAIVER OF CONTRACT DEFENSES

I understand that this Release is a binding contract pursuant to which I have released any and all claims against
Havelock Dive Club resulting in any way from my participation in the activities covered by this Release, INCLUDING
ANY CLAIMS CAUSED BY THE NEGLIGENCE OR CONTRIBUTORY NEGLIGENCE OF Havelock Dive Club, as set forth in
this Release.

6 CONTINUATION OF OBLIGATIONS

I agree that the terms and conditions of this Release shall continue in full force and effect now and in the future at all
times including (without limitation) during the period when I participate, either directly or indirectly, in the activities
covered by this Release, and shall be binding upon myself, executors, administrators, personal representatives, and/or
anyone else claiming on my behalf. This Release supersedes and replaces any prior agreement between the Release
and myself.

7. PHOTO & VIDEO RELEASE

I hereby grant Havelock Dive Club and its legal representatives and assigns (hereinafter collectively referred to as the
“Photographer”), the irrevocable and unrestricted right to capture, film, photograph, use and publish photographs,
images or audio-visual clips of me, or in which I may be included, with respect to my participation in the activities
covered by this Release for editorial, trade, advertising and any other purpose and in any manner and medium and in
any jurisdiction, to alter the same without restriction, and to copyright the same. This includes any and all uses that the
Photographer deems are necessary or desirable.

8 JURISDICTION

I agree and accept that this Release, and any matter, claim, suit, litigation or legal proceeding arising under this
Release (including its interpretation, validity and construction) shall be governed by and subject to the laws of India,
and the Laws shall apply to issues involving the construction, interpretation and validity of the Release, and that the
Laws shall govern any dispute arising from or related to this Release or the activities covered by this Release. Should
this Release be violated and a suit be brought against Havelock Dive Club, I hereby waive my right to a trial in any or all
jurisdictions, including but not limited to the Courts of India.

WITHOUT LIMITATION, I ACKNOWLEDGE AND AGREE THAT I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND
THAT IT IS A RELEASE OF ALL LIABILITY AND A WAIVER OF ANY RIGHT THAT I MAY HAVE TO BRING A LEGAL ACTION OR
ASSERT A CLAIM FOR INJURY OR LOSS OF ANY KIND AGAINST HAVELOCK DIVE CLUB. IF ANY ATTEMPT FOR CLAIM IS MADE,
I UNDERSTAND I WILL BE RESPONSIBLE FOR ALL DEFENSE COSTS INCURRED BY HAVELOCK DIVE CLUB.

With my signature below, I confirm that I have read the Release, been given the opportunity to review the terms and
conditions, ask questions, considered its effects, understand its content, given true information, and agree fully to the
terms as stated above.

SIGNATURE & DATE : PARENT SIGNATURE & DATE (IF MINOR) :