Name
    Surname
    Date of birth
    Diving center name
    Email
    Phone
    Date of activity
    1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.

    EXTRA Questions Section A (when answering Yes to question

    A1 - I HAVE/HAVE HAD: Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
    A2 - I HAVE/HAVE HAD: Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
    A3 - I HAVE/HAVE HAD: 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.
    A4 - I HAVE/HAVE HAD: Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
    A5 - I HAVE/HAVE HAD: Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.
    Has your answer been YES to any of these 4 EXTRA questions in Section A?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    2. I am over 45 years of age.

    EXTRA questions Section B (by answering Yes to question 2)

    B1 - I AM OVER 45 YEARS OF AGE AND: I currently smoke or inhale nicotine by other means.
    B2 - I AM OVER 45 YEARS OF AGE AND: I have a high cholesterol level.
    B3 - I AM OVER 45 YEARS OF AGE AND: I have high blood pressure.
    B4 - I AM OVER 45 YEARS OF AGE AND: 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).
    Has your answer been YES to any of these 4 EXTRA questions in Section B?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    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.
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    4. I have had problems with my eyes, ears, or nasal passages/sinuses.

    EXTRA questions Section C (by answering Yes to question 4)

    C1 - I HAVE/HAVE HAD: Sinus surgery within the last 6 months.
    C2 - I HAVE/HAVE HAD: Ear disease or ear surgery, hearing loss, or problems with balance.
    C3 - I HAVE/HAVE HAD: Recurrent sinusitis within the past 12 months.
    C4 - I HAVE/HAVE HAD: Eye surgery within the past 3 months.
    Has your answer been YES to any of these 4 EXTRA questions in Section C?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic
    injury or disease.

    EXTRA questions Section D (by answering Yes to question 6)

    D1 - I HAVE/HAVE HAD: Head injury with loss of consciousness within the past 5 years.
    D2 - I HAVE/HAVE HAD: Persistent neurologic injury or disease.
    D3 - I HAVE/HAVE HAD: Recurring migraine headaches within the past 12 months, or take medications to prevent them.
    D4 - I HAVE/HAVE HAD: Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
    D5 - I HAVE/HAVE HAD: Epilepsy, seizures, or convulsions, OR take medications to prevent them.
    Has your answer been YES to any of these 5 EXTRA questions in Section D?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    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.

    EXTRA questions Section E (by answering Yes to question 7)

    E1 - I HAVE/HAVE HAD: Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
    E2 - I HAVE/HAVE HAD: Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
    E3 - I HAVE/HAVE HAD: Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.
    E4 - I HAVE/HAVE HAD: An addiction to drugs or alcohol requiring treatment within the last 5 years.
    Has your answer been YES to any of these 4 EXTRA questions in Section E?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    8. I have had back problems, hernia, ulcers, or diabetes.

    EXTRA questions Section F (by answering Yes to question 8)

    F1 - I HAVE/HAVE HAD: Recurrent back problems in the last 6 months that limit my everyday activity.
    F2 - I HAVE/HAVE HAD: Back or spinal surgery within the last 12 months.
    F3 - I HAVE/HAVE HAD: Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.
    F4 - I HAVE/HAVE HAD: An uncorrected hernia that limits my physical abilities.
    F5 - I HAVE/HAVE HAD: Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
    Has your answer been YES to any of these 5 EXTRA questions in Section F?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    9. I have had stomach or intestine problems, including recent diarrhea.

    EXTRA questions Section G (by answering Yes to question 9)

    G1 - I HAVE/HAVE HAD: Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
    G2 - I HAVE/HAVE HAD: Dehydration requiring medical intervention within the last 7 days.
    G3 - I HAVE/HAVE HAD: Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
    G4 - I HAVE/HAVE HAD: Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
    G5 - I HAVE/HAVE HAD: Active or uncontrolled ulcerative colitis or Crohn’s disease.
    G6 - I HAVE/HAVE HAD: Bariatric surgery within the last 12 months.
    Has your answer been YES to any of these 6 EXTRA questions in Section G?
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.
    10. I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).
    DO NOT PROCEED WITH THE FORM!, download, read and accept the statement with the date and your signature, and take the Physician Evaluation Form to your doctor, for a medical evaluation. Participation in a diving training program requires the evaluation and approval of your physician.
    Download the Medical Questionnaire
    When you have it, send it to us by email info@tossasub.com, thanks.


    Declaration acceptance

    I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or from failure to disclose any existing or past health conditions.

    Signature

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