Diver Medical Check ( in English ) – papers.imcdiving.com

Medical Questionnaire

This questionnaire is designed to determine whether you need medical clearance from a physician before participating in diving activities. For your safety and the safety of others, please answer all questions honestly.
If you answer “Yes” to any question marked with (*), you must obtain a physician’s approval to dive. There are no exceptions.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *

Yes
No

1-1. Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease. *

Yes *
No

1-2. Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limit my physical activity/exercise. *

Yes *
No

1-3. A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. *

Yes *
No

1-4. Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *

Yes *
No

1-5. Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance *

Yes *
No

2. I am over 45 years of age. *

Yes
No

2-1. I have a high cholesterol level. *

Yes *
No

2-2. I have high blood pressure. *

Yes *
No

2-3. 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 disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). *

Yes *
No

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 or health reasons within the past 12 months. *

Yes *
No

4. I have had problems with my eyes, ears, or nasal passages/sinuses. *

Yes
No

4-1. Sinus surgery within the last 6 months. *

Yes *
No

4-2. Ear disease or ear surgery, hearing loss, or problems with balance. *

Yes *
No

4-3. Recurrent sinusitis within the past 12 months. *

Yes *
No

4-4. Eye surgery within the past 3 months. *

Yes *
No

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 persistent neurologic injury or disease. *

Yes
No

6-1. Head injury with loss of consciousness within the past 5 years. *

Yes *
No

6-2. Persistent neurologic injury or disease. *

Yes *
No

6-3. Recurring migraine headaches within the past 12 months, or take medications to prevent them. *

Yes *
No

6-4. Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *

Yes *
No

6-5. Epilepsy, seizures, or convulsions, OR take medications to prevent them. *

Yes *
No

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability. *

Yes
No

7-1. Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *

Yes *
No

the ongoing within

7-2. Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *

Yes *
No

7-3. Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation *

Yes *
No

7-4. An addiction to drugs or alcohol requiring treatment within the last 5 years. *

Yes *
No

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

Yes
No

8-1. Recurrent back problems in the last 6 months that limit my everyday activity. *

Yes *
No

8-2. Back or spinal surgery within the last 12 months. *

Yes *
No

8-3. Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *

Yes *
No

8-4. An uncorrected hernia that limits my physical abilities. *

Yes *
No

8-5. Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *

Yes *
No

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

Yes
No

9-1. Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *

Yes *
No

9-2. Dehydration requiring medical intervention within the last 7 days. *

Yes *
No

9-3. Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *

Yes *
No

9-4. Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *

Yes *
No

9-5. Active or uncontrolled ulcerative colitis or Crohn’s disease. *

Yes *
No

9-6. Bariatric surgery within the last 12 months. *

Yes *
No

10. I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam)). *

Yes *
No

⚠️ [ Medical Clearance Required ] Based on your answers, you must have a doctor’s approval to dive. If you do not bring a medical certificate, you cannot participate in diving. Please choose one option: *

I will bring a doctor’s certificate and participate in diving.
I will not bring a doctor’s certificate and will cancel my own diving only.
I will not bring a doctor’s certificate and will cancel the entire group’s diving.

Please refer to the email you will receive after submitting this form for further details regarding the medical certificate.

Customer Information

Medical Questionnaire