Medical Declaration Form (ISO type) Porfcipant Nome: Birthdate (dd/m/ yr HeReL pune Awal 4 704 /1g93 Bate (Azim / yon Al oct Loto Younues SALE FRORSSIONN SUBRSCIOOS. This is @ statement in which you are informed of some potential risks involved in recreational scuba diving and freediving and of the conduct required of you during the recreational scuba and freediving training. You must complete this Medical Declaration, which includes the medical-history information section, to enrol in the recreational scuba and freediving training programme. The purpose of this medical information sheet is to inform you whether you should be examined by a physician before participating in recreational diving training. If any of these conditions apply to you this does not necessarily disqualify you from recreational scuba diving. t only means that you must 5 the advice of a physician. Please acknowledge that you have read and understood the information provided below by initialling each individual point and sign at the Participant Signature. Please be advised that if ony of these items apply to you, for your own safety you must consult a Physician prior to participating in rusaedianad acehar ing and/or freediving. Note to women: if you are pregnant, or attempfing to become pregnant, do not dive. [YOU MUST CONSULT A PHYSICIAN IF: Initials You struggle fo perform moderate exercise (for example, walk 1.6 klometer/one mile in 14 minutes or swim) 200 meters/yards wihout resting), OR you have been unable o participate in a normol physical acviy due lo] MO finess or heabh reasons within the past 12 months. ou have had surgery wihin he last 12 months, OR you have ongoing problems related to past surgery. we Yc kit yn medications (with the ‘of birth control or ar arial drugs other thar gay a Ee see Fl You have od problems wh your kngs/brething, her, lod, or have been diagnosed wth COVID 19 end ro hvfhve ed: ‘ake _ ches surgery, heart srgery, hort wake surgery, ent plocenet, or © preumothorax (clopsed lng). = ‘hao, whoezing, severe legis, hay fee or congue ways wiki be lost T2monhstht ene your| Ay physical acivity/exercse. ts = A problem or ilness involving your heart such as: angina, chest pain on exertion, heart foilure, immersion pulmonary edema, hart atack or uroke, OR you ae ling medication for ony heart condos. ~ ere dis rd ely ping Wn pat 2 monks, hv en iced wih emplysona — A diagnosis of COVID-19. You are over 45 years of age and you have/have had: — Currently smoke or inhale nicotine by other means. — You have a high cholesterol level. = You have high blood pressure. Ho — You have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR| have o fami story of heat dice before ope 50 nding abnormal het yh, corenary ery isease or cardiomyopathy] Please turn overYou have had problems wi 7 Sous ey aon wher e765, eas, or nasal passages/sinuses and you bave/have had: = Recurrent oR 22" surgery, hearing loss, OR problems with balance. = Bye surges within the post 12 months. ‘urgery within the past 3 months, i ; had migraine headaches, seizures, Peed eco ro disease ond re Teve/hewe hd. - ie consciousness within the ‘5 years. ~ Heitor ‘neurologic injury or disease. ae w 7 Bled’ migraine headaches within the past 12 months, OR fake medications fo prevent them. ~ i ts OR fainting (full/partil loss of consciousness) wihin the ast 5 years. 5 ilepsy, seizures, or convulsions, OR fake medications to prevent them. ov are curenly undergoing treolment [OR have required ecient win the lst ve yeas) For psychological problems, personaly Fea a eee, OR an eddicion to drugs or aloha; OR, you have been agnosed wth laming dsc and you hove/have hod: = Behavioral heoth mentl or psychological problems requiring medical/psyhicrcreokneny 7 = Major depression, suicidal ideation, panic otfacks, uncontrolled bipolar disorder requiring] Mo medication/psychiatric treatment. . . — Been diagnosed with a mental health condition OR o leaning/developmental disorder that requires ongoing) care. — An addiction fo drugs or alcohol requiring treatment within the last 5 yeors. You hove had back problems, hemia, ulcers, or diabetes and you have/have hod: — Recurrent back problems in the last 6 months that limit your ‘everyday acivity. = Back or spinal surgery within the last 12 months. We — Diabetes, either drug: or diet-controlled, OR gestational diabetes within the last 12 months. — An uncorrected hemia that limits your physical abilities. = ‘ative or untreated ulcers, problem wounds, OR ulcer surgery within the last 6 months. stroke, significant head injury, OR suffer from, You have had siomach or intestine problems, induding recent diarrhea and you hove/have had: = Ostomy surgery and do not have medical cleorance to swim OR engage in physical activity. = Dehydration requiring medical intervention within the last 7 days. — patze or untected stomach OR intestinal ulcers OR vler surgery within the lst 6 months. {bo — Frequent heartbumn, regurgitation, OR gastroesophageal reflux disease (GERD) — Active or uncontrolled ulcerative colitis OR Crohn's disease. = Bariatric surgery within the last 12 months. IF any ofall the condifons above applies to you, take this form and the Physician's Evaluation Forty toa physician for « medical evaluation. Participation ina diving course requires a physician’s approval if none of the conditions above applies to you, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it. PARTICIPANT SIGNATURE Pericipant Statement: | have read ond understood the information provided below, and | confirm none of the above conditone applies ome. If ony of hese conditions opply to me ond | miss to be exomined by a physician before eatcioting’ hs recreatonl diving trcining | understand that | occeptresponsbiliy for any consequences resuling from my failure to. ‘e by a physicion. Poriicipant Signature (or, fa minor, participant's parent/guardian signature required.) Date (dd/mm/yyyy) ur ~ we PSS Worldwide 2020 ws Mesiol Dedrtion Form conforms to ISO Standards 24801 Annex A and DAN-WRSTC-UHMS Diver Medical Screen ‘ommitteo's indications