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SCUBA DIVING FORM

Please complete one per person

There are two sections to this form -  Section 1. SCUBA DIVING INFORMATION and Section 2. SCUBA DIVERS MEDICAL STATEMENT. Please be sure to complete and submit both sections

 

Section 1. SCUBA DIVING INFORMATION

 
Select the expedition this information pertains to.
First / Middle / Last Name
Select the agency in which you are certified with.
If you selected "Other" please specify other Scuba Agency.
Date of Certification *
Date of Certification
Date of Last Dive *
Date of Last Dive
Please indicate "None" if not Nitrox certified.
I prefer to dive Nitrox *
Where possible I prefer to dive Nitrox
 
 

 

Section 2. PADI MEDICAL STATEMENT

It is your responsibility to check with your physician to ensure that you are fit and healthy to undertake the expedition and to participate in the scuba diving portion of the trip. Wild Earth Expeditions highly recommend that you do a physical check up by your Physician prior to the expedition, or at least on an annual basis. This is solely for your benefit and to ensure that you are fit to dive. You MUST complete this PADI Dive Medical Statement to enrol in the scuba diving portion of this expedition.

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

To scuba dive safely, you should 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 coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular  basis, you MUST consult your doctor before participating in this expedition, and should on a regular basis thereafter.  Improper use of scuba equipment can result in serious injury. 

PADI DIVER MEDICAL QUESTIONNAIRE

The purpose of this Medical Statement is to find out if you should be examined by your doctor before participating in scuba diving on this expedition. Please answer the following questions on your medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, your physician MUST complete the Physician’s Medical Clearance Letter and/or Wild Earth Expeditions must receive a Doctor’s certificate indicating that you are fit to dive prior to participating in scuba diving on this expedition.

 
Full Name (as stated in your passport) First / Middle / Last Name
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- currently smoke a pipe, cigars or cigarettes - have a high cholesterol level - have a family history of heart attacks or strokes - high blood pressure - diabetes mellitus, even if controlled by diet alone
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Electronic Signature *
The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.
Todays Date *
Todays Date