Blue Planet Diving - Medical form

Name

Last name

Date of birth

E-mail

Emergency contact (name/phone)

Level of certification

Total dives number

Year of the last dive

*please note that upon arrival at our center you should present your certificate and log to our instructors so bring them with.

Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI® Members (“Members”), including Blue Planet Diving Center, Dubrovnik, and/or any individual PADI Instructors and Divemasters associated with the program in which I am participating, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI EMEA Ltd., PADI Americas, Inc., or its parent, subsidiary and affiliated corporations (“PADI”).
I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the operation of the Members’ business activities and the day-to-day conduct of PADI programs and supervision of divers by the Members or their associated staff.

This is a statement in which you, the certified diver, or a student diver under the control and supervision of a certified scuba instructor, are informed that skin diving, freediving and scuba diving have inherent risks, including those risks associated with boat travel to and from the dive site. The statement also sets out the circumstances in which you participate in the diving experience at your own risk.
Your signature on this statement is required as proof that you have received, read and understood this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then you should discuss it with your instructor. If you are a minor, this form must also be signed by a parent or guardian.

Skin diving, freediving and scuba diving have inherent risks which may result in serious injury or death. Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. Risks also include slipping or falling while on board a boat, if one is used, being cut or struck by a boat while in the water, injuries occurring while getting on or off a boat, and other perils of the sea. Open water diving trips that may be necessary for this experience may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. Skin diving, freediving and scuba diving are physically strenuous activities and you will be exerting yourself during this diving experience. Past or present medical conditions may be contraindicative to your participation in this experience. You must be in good mental and physical fitness for diving, and not under the influence of alcohol, nor any drugs that are contraindicatory to diving. If you are taking medications, you affirm that you have seen a physician and have approval to dive under the influence of the medications/drugs. You must inspect all of your equipment prior to this experience and notify the dive professionals and the facility through which this experience is offered if any of your equipment is not working properly.
If diving from a boat, you must be present at and attentive to the briefing given by the boat crew. If there is anything you do not understand you will notify the boat crew or captain immediately. You must follow safe dive practices and plan dives as no-decompression dives and within parameters that allow a safety stop before ascending to the surface, arriving on board the vessel with gas remaining in your cylinder as a measure of safety. If distressed on the surface, you must immediately drop your weights and inflate your BCD (orally or with the low pressure inflator) to establish buoyancy on the surface.
If a Guide is present to assist during the dive, and you choose to dive with the Guide, it is your responsibility to stay in proximity to the Guide during the dive.

I understand and agree that neither the dive professionals conducting this program, nor the facility through which this program is conducted, Blue Planet Diving Center, Dubrovnik, nor PADI EMEA Ltd., nor PADI Americas, Inc. nor their affiliate or subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns accept any responsibility for any death, injury or other loss suffered by me to the extent that it results from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.

In the absence of any negligence or other breach of duty by the dive professionals conducting this program, the facility through which this program is offered, PADI EMEA Ltd., PADI Americas, Inc. and all parties referred to above, my participation in this diving program is entirely at my own risk.

I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT AND STATEMENT OF RISK AND LIABILITY BY READING BOTH BEFORE SIGNING THESE STATEMENTS.

I acknowledge and agree that this Diver Activities form will be effective for one (1) year from the date on which I sign for any skin diving, freediving or scuba diving activities in which I participate with the named PADI Members

Diver Accident Insurance?

Policy Number:

Standard Safe Diving Practices Statement of Understanding

This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safety in diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Read and discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian. I understand that as a diver I should:

1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information.

2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specifically trained to do so.

3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pressure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—whichever you are trained to use) when scuba diving. Deny use of my equipment to uncertified divers.

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months.

5. Adhere to the buddy system throughout every dive. Plan dives – including communications, procedures for reuniting in case of separation and emergency procedures – with my buddy.

6. Be proficient in dive planning (dive computer or dive table use). Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver – Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer.

7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signaling device (such as signal tube, whistle, mirror).

8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations.

9. Use a boat, float or other surface support station, whenever feasible.

10. Know and obey local dive laws and regulations, including fish and game and dive flag laws.

I understand the importance and purposes of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

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

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

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

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.

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

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

2. I am over 45 years of age.

I currently smoke or inhale nicotine by other means.

I have a high cholesterol level.

I have high blood pressure.

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).

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.

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

Sinus surgery within the last 6 months.

Ear disease or ear surgery, hearing loss, or problems with balance.

Recurrent sinusitis within the past 12 months.

Eye surgery within the past 3 months.

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

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

Head injury with loss of consciousness within the past 5 years.

Persistent neurologic injury or disease.

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

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

Epilepsy, seizures, or convulsions, OR take medications to prevent them.

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.

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

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

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

An addiction to drugs or alcohol requiring treatment within the last 5 years.

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

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

Back or spinal surgery within the last 12 months.

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

An uncorrected hernia that limits my physical abilities.

Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

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

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

Dehydration requiring medical intervention within the last 7 days.

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

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

Active or uncontrolled ulcerative colitis or Crohn’s disease.

Bariatric surgery within the last 12 months.

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

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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I am hereby submitting this form to the Diving Center Blue Planet Dubrovnik and vouching the data entered is true and correct. I also understand that these documents are legally binding and release the Diving Center Blue Planet Dubrovnik from all liability connected to the situations that may occur as a consequence related to the questionnaire topics.

Click „submit“ if you understood that this form is legally binding.

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