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Medical Questionnaire

Diver medical report

Participant questionnaire (Confidential)

Diving requires good physical and mental health. There are some medical conditions that can be dangerous during diving and are listed below. This questionnaire is designed primarily as an initial medical screening for new divers, but is also appropriate for those receiving continuing education. If you have any concerns about your physical condition that are not represented on this form, consult your doctor before diving. For your safety and the safety of others who may dive with you, answer all questions honestly.

Complete this questionnaire as a prerequisite for snorkeling or recreational diving.

For women: If you are pregnant or trying to become pregnant, do not dive.

    Personal information

    Questionnaire

    1. I have had problems with my lungs or breathing, heart or blood

    YesNo

    2. I am over 45 years old (Answer YES only if you have cholesterol, hypertension or are a smoker)

    YesNo

    3. I have difficulty performing moderate exercise (for example, walking 1.6 km in 12 minutes or swimming 200 meters without resting) or I have not been able to participate in normal physical activity due to physical or health reasons in the last 12 months

    YesNo

    4. I have had problems with my ears or nasal passages or sinuses

    YesNo

    5. I have had surgery in the last 12 months, or I have continuous problems related to previous surgery

    YesNo

    6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffered from persistent neurological injury or disease

    YesNo

    7. I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or a drug or alcohol addiction

    YesNo

    8. I have had back problems, hernias, ulcers, or diabetes

    YesNo

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

    YesNo

    10. I am taking prescription medications (with the exception of contraceptives or antimalarial drugs)

    YesNo

    Table A - I have/have had

    Thoracic, cardiac, heart valve surgery, stent placement, or pneumothorax (collapsed lung).

    YesNo

    Asthma, wheezing, severe allergies, hay fever, or congested airways in the last 12 months that limit my physical activity or exercise.

    YesNo

    A problem or disease involving my heart such as: angina pectoris, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy or stroke, or I am taking medication for any heart condition.

    YesNo

    Recurrent bronchitis and persistent cough in the last 12 months, or have been diagnosed with emphysema.

    YesNo

    Table B - I am over 45 years old and:

    I currently smoke or inhale nicotine by other means.

    YesNo

    I have high cholesterol.

    YesNo

    I have high blood pressure.

    YesNo

    I have had a family member (1st or 2nd degree relative) who died of sudden death or heart disease or stroke before the age of 50 (including abnormal heart rhythms, coronary artery disease, or cardiomyopathy).

    YesNo

    Table C - I have/have had

    Sinus surgery in the last 6 months.

    YesNo

    Ear diseases or ear surgery, hearing loss, or balance disturbances.

    YesNo

    Recurrent sinusitis in the last 12 months.

    YesNo

    Eye surgery in the last 3 months.

    YesNo

    Table D - I have/have had

    Head injury with loss of consciousness in the last 5 years.

    YesNo

    Persistent neurological injuries or diseases.

    YesNo

    Recurrent migraine headaches in the last 12 months or taking medication to prevent them.

    YesNo

    Fainting or blackouts (total/partial loss of consciousness) in the last 5 years.

    YesNo

    Epilepsy, seizures or convulsions, or I take medication to prevent them.

    YesNo

    Table E - I have/have had

    Behavioral health, mental or psychological problems requiring medical or psychiatric treatment.

    YesNo

    Major depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder requiring psychiatric treatment.

    YesNo

    I have been diagnosed with a mental health condition or a learning or developmental disorder requiring treatment in the last 5 years.

    YesNo

    Table F - I have/have had

    Recurrent back problems in the last 6 months that limit my daily activity.

    YesNo

    Back or spinal surgery in the last 12 months.

    YesNo

    Diabetes, whether controlled by insulin or diet, or gestational diabetes in the last 12 months.

    YesNo

    An uncorrected hernia that limits my physical abilities.

    YesNo

    Active or untreated ulcers, problematic wounds, or ulcer surgery in the last 6 months.

    YesNo

    Table G - I have/have had

    Ostomy surgery and I do not have medical authorization to swim or participate in physical activity.

    YesNo

    Dehydration requiring medical intervention in the last 7 days.

    YesNo

    Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.

    YesNo

    Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).

    YesNo

    Active or uncontrolled ulcerative colitis or Crohn's disease.

    YesNo

    Bariatric surgery in the last 12 months.

    YesNo

    If you answered NO to the 10 previous questions, a medical evaluation is not required. If you are over 45 years old but do not smoke, do not have cholesterol, high blood pressure or a family history of heart disease, you do not need a medical evaluation either, although it is advisable to have a medical check-up every two years from that age to dive.

    Participant statement: I have answered all questions honestly, I understand that I accept responsibility for any consequences resulting from any question I may have answered inaccurately or for not having disclosed any existing or past health condition.

    IMPORTANT

    If you answered YES to questions 3, 5, or 10 above, then you need a medical examination. Complete the entire form. You know that we can arrange an appointment with our specialist doctor in hyperbaric medicine and have it done at our center. Call us and we’ll organize it whenever you want.

    Personal data protection. In compliance with art. 13 of the GDPR and art. 11 of the LOPDGDD, we inform you of the following terms:

    1. The purpose of data processing is to comply with the application of the new Royal Decree 550/2020, of June 2, which determines the safety conditions for diving activities. This RD legitimizes the collection of the requested health data.
    2. To register for and practice diving activities, you must answer this questionnaire in order to guarantee safety in the practice of said activity. Otherwise, you will not be able to register or practice said activity. The data provided will only be used for the purpose stated above.
    3. We have adopted the technical and organizational measures to guarantee the security and confidentiality of the medical data provided.
    4. Your data will be kept as long as you practice this activity or do not request its deletion, and must be updated by you in case of changes in your health status.
    5. Your data will not be transferred unless legally required or necessary for the provision of the service.
    6. You have the right to exercise your rights: access, rectification, deletion, limitation, portability, opposition and not to be subject to automated individual decisions by contacting planeta@planeta-azul.com attaching a photocopy of your ID.
    7. You can also file the corresponding claim with the Spanish Data Protection Agency if you believe that we have violated any of your rights. You can request additional information about the processing of your data in our offices or through email.