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Please complete one per person

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



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
Have you ever dived at night? *
Have you ever dived in currents? *



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 the 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. 


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 you answer YES to any of the items, your physician MUST complete the Physician’s Medical Clearance Letter (on 2nd page of statement form) 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.



  1. “Click” the button to open the PADI Diver Medical Statement Form in your web browser.

  2. You can complete the PADI Diver Medical Statement online in your web browser by “clicking” to place your curser in the blue highlighted areas and typing YES or NO next to each question. “Right Click” anywhere on the form and “Select - Save As” to download a copy of your completed form.

  3. OR “Click” the download icon (arrow pointing down) in the top right corner of the web browser screen to download. Fill in form.

  4. Print and sign the completed form.

  5. If you have answered YES to any of the items, you are required to complete the personal section labelled “Student” and have your Physician access your health, complete and sign the “Physicians” section on page 2 of the form.

  6. Please clearly Scan or Photograph all completed pages of the form and email to our team at Wild Earth Expeditions at info@WildEarthExpeditions.com before the trip commences if you intend on participating in Scuba diving.