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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 specify metres or feet.
Please indicate "None" if not Nitrox certified.
I prefer to dive Nitrox *
Where possible I prefer to dive Nitrox
Have you ever dived in currents? *
Have you ever dived at night? *
 
 

 

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 (12 month) 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 STATEMENT QUESTIONNAIRE

The purpose of this PADI Diver Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational scuba diving on this expedition. 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 prior to engaging in dive activities.

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, we must request that you consult with a physician to assess your health and fitness prior to participating in scuba diving. 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 *
Todays Date *
Todays Date
Physician's Medical Clearance Letter *
If you have answered YES to any of the above, we must request that you consult with a physician to assess your health prior to participating in scuba diving. 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. Before the trip commences if I intend on participating in the Scuba diving I understand that: