Medical History Questionnaire

Required for all courses

By answering the following questions, you will help us determine whether you must obtain a physician’s approval for scuba diving before the start of your class. This is something you need to do right now and not put off until later.

You must answer each questions with either a Yes or No. All answers are required. Please note the questions apply whether you currently suffer from a condition or have in the past. We keep all information you supply confidential.

Note to women: If you are pregnant or attempting to become pregnant, do not dive.

Your name

Email Address

I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.

Yes No

I am over 45 years of age.

Yes No

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

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

Yes No

I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes No

I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

Yes No

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 disability.

Yes No

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

Yes No

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

Yes No

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

Yes No

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4709 Airline Drive
Metairie, LA 70001
(504) 888-4882

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Tuesday-Friday • 11-6
Saturday • 9-4
Closed Sunday-Monday