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Professional Diving Instructors Corporation International

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Participant Record
(Confidential Information)

Please read carefully before signing.
This is a statement in which you are informed of some potential risks involved 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 offered by Lynn Marchant (instructor) and Mermaid Scuba/Dive Utah (facility) located in the city of Holiday/Ogden and State of Utah.

Read and discuss this statement prior to signing it. You must complete this Medical Statement, which includes the medical-history section, to enroll in the scuba-training program. If you are a minor, you must have this Statement signed by a parent.

Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there are dangers.

To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor and the instructor before participation in this program. You will also need to learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.

If you have any additional questions regarding this Medical Statement or the Medical History section, review them with your instructor before signing.

To the Participant:
The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with a PDIC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

______ Could you be pregnant or are you attempting to become pregnant?
______ Do you regularly take prescription or nonprescription medications?
              (with the exception of birth control)
______ Are you over 45 years of age and have one or more of the following?
              *currently smoke a pipe, cigars, or cigarettes
              *have a high cholesterol level
              *have a family history of heart attacks or strokes

Have you ever had or do you currently have...
______ Asthma, or wheezing with breathing, or wheezing with exercise?
______ Frequent or severe attacks of hayfever or allergy?
______ Frequent colds, sinusitis or bronchitis?
______ Any form of lung disease?
______ Pneumothorax (collapsed lung)?
______ History of chest surgery?
______ Claustrophobia or agoraphobia (fear of closed or open spaces)?
______ Behavioral health problems?
______ Epilepsy, seizures, convulsions or take medications to prevent them?
______ Recurring migraine headaches or take medications to prevent them?
______ History of blackouts or fainting (full/partial loss of consciousness)?
______ Do you frequently suffer from motion sickness (seasick, carsick, etc.)?
______ History of diving accidents or decompression sickness?
______ History of recurrent back problems?
______ History of back surgery?
______ History of diabetes?
______ History of back, arm or leg problems following surgery, injury or fracture?
______ History of high blood pressure ortake medicine to control blood pressure?
______ History of any heart disease?
______ History of heart attacks?
______ Angina (heart or blood vessel surgery)?
______ History of ear or sinus surgery?
______ History of ear disease, hearing loss or problems with balance?
______ History of problems equalizing (popping) ears with airplane or mountain travel?
______ History of bleeding or other blood disorders?
______ History of any type of hernia?
______ History of ulcers or ulcer surgery?
______ History of colostomy?
______ History of drug or alcohol abuse?

The Information I have provided about my medical history is accurate to the best of my knowledge.

_______________________________________________________ Date ___________

_______________________________________________________ Date ___________
Signature of Parent or Guardian Where Applicable