Choose a Location:

Employer:

Date:

Last Name:

First Name:

Middle Name:

Address:

Address 2:

City/Town:

State/Province:

Country:

Zip/Postal Code:

Telephone Number:

Date of Birth:

SSN:

Gender:

Spouse Name:

Height:

Weight:

Dept:

My Present State of Health is:

Skin Rash/Allergies:

Epilepsy/Seizure:

Disabling Headaches:

Uncorrectable Vision:

Eye Trouble (not glasses):

Defective Hearing:

Perforated Eardrum:

Nose Bleed:

Chest Pain:

High Blood Pressure:

Abnormal Heart Rhythm:

Asthma:

Tuberculosis:

Lung Trouble:

Gallbladder Trouble:

Jaundice:

Liver Disease:

Kidney Problems:

Heart Murmur:

Rheumatic Fever:

Rheumatism:

Dislocations:

Muscle Weakness:

Shoulder Injury:

Broken Bones:

Swollen Ankles:

Elbow Injury:

Tumor or Cancer:

Blood Disease:

Varicose Veins:

Convulsions:

Head Injury:

Nervous Breakdown:

Color Vision Defect:

Eye Surgery:

Ear Trouble:

Hay Fever:

Air Obstruction:

Cardiac Problems:

Heart Attack:

Fainting Spells:

Coughing up Blood:

Shortness of Breath:

Freq Chronic Cough:

Stomach Trouble:

Hernia:

Appendicitis:

Urological Problems:

Rectal Problems:

Migraines:

Back Strain:

Paralysis:

Knee Injury/Trick Knee:

Arthritis:

Disc Problems:

Foot Trouble:

Diabetes:

Thyroid Disease:

Difficult Menses:

Pregnant:

If you have answered yes to any of the above please explain in detail below:

Surgery/Condition:

Year:

Surgery/Condition (2):

Year (2):

Surgery/Condition (3):

Year (3):

1. Do you have any physical defects or any partial disabilities?:

2. Do you have any conditions that may require special work assignment?:

3. Have you ever been rejected or rated for insurance, employment, or armed forces for health reasons?:

4. Have you had significant exposure to mining dust, asbestos, silica or toxic chemicals?:

5. Do you have work history of dust exposure?:

6. Did you ever have any difficulty when using a respirator?:

7. Have you ever had ill effects from any work that you have done?:

8. Have you ever resigned, terminated or changed jobs for medical reasons?:

9. Have you ever been dismissed from employment because of use of alcohol or drugs?:

10. Do you presently use marijuana, LSD, narcotics, or controlled substances?:

11. Do you have any allergies or reactions to food, chemicals, drugs, insect stings or marine life?:

12. Have you ever suffered from a stroke or TIA?:

13. Do you have emphysema or chronic bronchitis?:

14. Do you have persistent phlegm (most days for 3 or more months/years)?:

15. Have you ever had a collapsed lung?:

16. Have you ever had a reduced lung function on a breathing tests:

17. Have you ever had an abnormal chest x-ray?:

18. Have you ever had an operation or serious injury to your chest?:

19. Do you suffer from dizziness?:

20. Do you excessively use alcohol or have a drug dependence?:

21. Do you suffer from claustrophobia (fear of tight or confined spaces)?:

22. Have you ever suffered from hyperventilation (over breathing)?:

23. Do you ever have the sensation of choking or smothering?:

24. Have you ever suffered from heatstroke or heat exhaustion?:

25. Do you wear glasses or contacts?:

26. Do you use a hearing aid?:

27. Have you ever had a injury, surgery or deformity to your face?:

28. Do you wear dentures?:

29. Have you ever lost fingers or experienced difficulty using hands or fingers?:

30. Do you now or have you ever smoked cigarettes, cigars, or pipes?:

Explanation and comments to questions answered yes:

1. Are you currently under a doctor's care?:

2. Do you take any medication? If so please list below.:

3. How long have you been diving?:

4. Max. depth surface air:

5. Surface Mixed Gases:

6. Longest bottom time air:

7. Have you ever made any saturation dives?:

8. When was your last dive?:

9. What was your deepest dive?:

10. How many dives?:

11. Certified by and when?:

12. Diving Experience (number of years experience):

Air:

Mixed Gases:

Saturation:

Have you passed an oxygen tolerance test?:

13. Number of decompression incidents? (If none, list zero (0) for each field.):

Bends: pain only:

Bends: neurological:

Serious Symptoms: chokes:

Serious Symptoms: inner ear:

List any residuals:

14. Have you been involved in a diving accident/incident since your last physical examination?:

15. Date of last physical examination.:

16. For what company or organization were you examined?:

17. Name of address of physician who performed your last examination.:

18. In diving have you had a history of:

Gas Embolism:

Oxygen Toxicity:

CO2 Toxicity:

CO Toxicity:

Ear Squeeze:

Ear Drum Rupture:

Sinus Squeeze:

Deafness:

Lung Squeeze:

Near Drowning:

Asphyxiation:

Vertigo (dizziness):

Pneumothorax:

Nitrogen Narcosis:

Loss of Consciousness:

If you answered yes to any of the above, please provide details and severity of each:

19. Have you ever had any of the following?:

Chest X-Ray:

Long Bone Series:

Back (spine) X-Ray:

ENG:

EEG:

EMG:

Nerve Condition Studies:

Pulomonary Function Studies:

Audiogram:

EKG:

Exercise EKG:

Treadmill EKG:

If you answered yes to any of the above, please list the approximate date of each:

20. Asthma:

Do you currently experience or have you ever experienced asthma?:

Ever been hospitalized as a result of an asthma attack?:

Do you use an inhalers or nebulizer?: