Please Note:

This special PADI medical form is NOT required of all U.S. Dive Travel (USDT) clients. Rather, the only clients whom we ask to fill out this form ( & return it to USDT ) are those persons who already know, or suspect, that they have one or more serious medical conditions that might affect their personal safety while scuba diving.

U.S. Dive Travel has only one motive in providing this PADI form -- not to meddle or annoy -- but only to increase your diving safety margin to the very highest degree possible. That's because we truly care about the health & well-being of our clients. After all, we consider you friends first, then business associates later. That is the U.S. Dive Travel way of doing business.

So please be fully frank with us about your medical history. Please do not conceal any serious or chronic medical conditions you know to exist. We promise to work with you as closely as possible, in case there are questions, to help you take your vacation as planned -- if that is medically allowed by your personal doctor or the physicians examining you. With these rules in place, we all can do the best & safest job possible in planning your dive vacation. Thank you very much for your time & consideration.

John & Susan Hessburg
Founders, Managers
U.S. Dive Travel Network
St. Paul, MN, U.S.A.

PADI ® SCUBA DIVING MEDICAL STATEMENT

Endorsed by the Recreational Scuba Training Council -- RSTC.

(Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.

This is a statement in which you are informed of some potential risks involved in scuba diving. Your signature on this statement is required in order to participate in the scuba excursion offered by (your dive vacation planning company) U.S. DIVE TRAVEL

and facility ____________________________________________________

located in the city of __________________________________________

and the state / country of ______________________________________ 

Read and discuss this statement prior to signing it. You must complete this Scuba Diving Medical Statement, which includes the medical history section, to participate in the scuba excursion. If you are a minor, you must have the Scuba Diving Medical Statement signed by a parent or guardian.

Scuba diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there are dangers. To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory & circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs, should not dive. If taking medication, consult your doctor before participating in scuba diving.

If you have any additional questions regarding this Scuba Diving Medical Statement, review them with the excursion operator before signing.

MEDICAL HISTORY

To the Diver:

The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving and you must seek the advice of your physician.

Please answer the following questions on your past or present 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 prior to participating in scuba diving. Your excursion operator / coordinator will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

_______ Could you be pregnant or are you attempting to become pregnant?

_______ Do you regularly take prescription or non-prescription medications? 

        (with the exception of birth control)

_______ Are you over 45 years of age and have one or more of the following: 

        currently smoke a pipe, cigars or cigarettes? have a high cholesterol 

        level? have a family history of heart attacks or strokes?

Have you ever had or do you currently have...

_______ Asthma, or wheezing with breathing, or wheezing with exercise?

_______ Frequent or severe attacks of hay fever or allergy?

_______ Frequent colds, sinusitis or bronchitis?

_______ Any form of lung disease?

_______ Pneumothorax (collapsed lung?)

_______ History of chest surgery?

_______ Claustrophobia or agoraphobia (fear of closed or open spaces)?

_______ Behavioral health problems?

_______ Epilepsy, seizures, convulsions or do you take medications to prevent them?

_______ Recurring migraine headaches or do you take medications to prevent them?

_______ History of blackouts or fainting (full or partial loss of consciousness)?

_______ Do you frequently suffer from motion sickness (seasick, carsick, etc.?)

_______ History of diving accidents or decompression sickness?

_______ History of recurrent back problems?

_______ History of back surgery?

_______ History of diabetes?

_______ History of back, arm or leg problems following surgery, injury or fracture?

_______ Inability to perform moderate exercise (example: walking one mile within 12 minutes)?

_______ History or high blood pressure or do you take medication to control blood pressure?

_______ History of any heart disease?

_______ History of heart attacks?

_______ Angina or heart surgery or blood vessel surgery?

_______ History of ear or sinus surgery?

_______ History of ear disease, hearing loss or problems with balance?

_______ History of problems equalizing (popping) ears with airplane or mountain travel?

_______ History of bleeding or other blood disorders?

_______ History of any type of hernia?

_______ History of ulcers or ulcer surgery?

_______ History of colostomy?

_______ History of drug or alcohol abuse?

This information I have provided about my medical history is accurate to the best of my knowledge.

Diver Signature ____________________________________________________

Parent / Guardian Signature ________________________________________ 

Date of Signature _______________________________

This PADI Form is Product Number 10065 / © International PADI, Inc. Reprinted with permission from PADI's HQ office.

IMPORTANT NOTE TO CLIENTS:

Once you have read this questionnaire carefully & signed it, please send it to:

Sincerely,

John & Susan Hessburg,
Founders, Managers
U.S. Dive Travel Network
St. Paul, MN, U.S.A.