NAUI Medical Form / Release Form

Please print or type NAME ___________________________________________________________________________

ADDRESS __________________________________________________________________________________________________

CITY ____________________________________________________

STATE/PROVINCE ________

ZIP_______________________

HOME PHONE___________________________

 

To the Instructor: If any condition listed on the medical history form in the student record folder is checked by the student, you are required to individually interview the student. If, as a result of the interview, you are unsure whether or not the condition is a contraindication to diver training send the student to a physician for a medical exam. In the event that referral to a physician is necessary, provide the student with this NAUI Medical Form and transfer the student’s medical history and any notes to the copy to take with them to the physician. To the Physician: This person is an applicant for training in diving with self-contained underwater breathing apparatus (SCUBA). This is an activity which puts unusual stress on the individual in several ways. A list of contraindications is on the reverse of this form for your reference.

 

The student applicant’s medical history below was provided during the enrollment process.

—— Behavioral health problems

—— Bronchitis

—— Contact lenses

—— Claustrophobia

—— Tuberculosis

—— Dental plates

—— Agoraphobia

—— Respiratory problems

—— Physical disability

—— Migraine headaches

—— Back Problems

—— Serious injury

—— Epilepsy

—— Back/spinal surgery

—— Over 40 years old

—— Ear or hearing problems

—— Diabetes

—— Hepatitis

—— Trouble equalizing pressure

—— Ulcers

—— Regular medication

—— Sinus trouble

—— Colostomy

—— Drug allergies

—— Severe hayfever

—— Hernia

—— Alcohol or drug abuse

—— Heart trouble

—— Dizziness or fainting

—— Rejected from any activity

—— High blood pressure

—— Recent surgery for medical reasons

—— Angina

—— Hospitalized

—— Any medical condition not listed:

—— Heart surgery

—— Pregnant

—— Asthma

—— Motion Sickness

____________________________________________________________

Notes : PLEASE RETURN THIS FORM TO

 

THE STUDENT APPLICANT Please note that the medical examination form presents a choice under IMPRESSION. We can only accept unconditional approval as stated for student applicants desiring to begin or continue training. If you conclude that diving is not in the individual’s best interest or that their medical condition is likely to present a probable direct threat to others, please discuss your opinion with the person and check disapproval. IMPRESSION:

___ APPROVAL (I find no medical conditions I consider incompatible with diving.)

___ DISAPPROVAL ( This applicant has medical conditions which in my opinion clearly would constitute unacceptable hazards to health and safety in diving.)

 

Date_________________________

Signature ___________________________________________________________________ ,

MD. Physician’s Name (print) __________________________________________________________________________ 

Address ______________________________________________________________________________________________________________________________________________________

Phone _______________________

 

Copyright © 2013 NAUI Worldwide MEDICAL EVALUATION AND PHYSICIAN APPROVAL FORM This list of relative and absolute contraindications is not all inclusive. Contraindications that are absolute permanently place the diver and his diving partners at increased risk for injury or death. Relative contraindications to scuba may be resolved with time and proper medical intervention or may be intermittent. A bibliography is included to aid in clarifying issues that arise. The Divers Alert Network (DAN) physicians are available for consultation by phone (919) 684-2948 during normal business hours. For diving related emergencies call, DAN at (919) 684-9111 24 hours, 7 days a week. OTOLARYNGOLOGICAL Relative Contraindications: • History of... –significant cold injury to pinna –TM perforation –tympanoplasty –mastoidectomy –mid-face fracture –head and/or neck therapeutic radiation –temporomandibular joint dysfunction • Recurrent otitis externa • Significant obstruction of the external auditory canal • Eustachian tube dysfunction • Recurrent otitis media or sinusitis • Significant conductive or sensorineural hearing impairment • Facial nerve paralysis not associated with barotrauma • Full prosthodontic devices • Unhealed oral surgery sites Absolute Contraindications: • History of... –stapedectomy –ossicular chain surgery –inner ear surgery –round window rupture –vestibular decompression sickness • Monomeric TM • Open TM perforation • Tube myringotomy • Facial nerve paralysis secondary to barotrauma • Inner ear disease other than presbycusis • Uncorrected upper airway obstruction • Laryngectomy or status post partial laryngectomy • Tracheostomy • Uncorrected laryngocele NEUROLOGICAL Relative Contraindications: • History of... –head injury with sequelae other than seizure –spinal cord or brain injury without residual neurologic deficit –cerebral gas embolism without residual, pulmonary air trapping has been excluded • Migraine headaches whose symptoms or severity impair motor or cognitive function • Herniated nucleus pulposus • Peripheral neuropathy • Trigeminal neuralgia • Cerebral palsy in the absence of seizure activity Copyright © 2013 NAUI Worldwide Absolute Contraindications: • History of... –seizures other than childhood febrile seizures –TIA or CVA –spinal cord injury, disease or surgery with residual sequelae –Type II (serious and/or central nervous system) decompression sickness with permanent neurologic deficit • Intracranial tumor or aneurysm CARDIOVASCULAR Relative Contraindications: The suggested minimum criteria for stress testing is 13 METS. • History of... –CABG or PCTA for CAD –myocardial infarction –dysrhythmia requiring medication for suppression • Hypertension • Valvular regurgitation • Asymptomatic mitral valve prolapse • Pacemakers-Note: Pacemakers must be depth certified by the manufacturer to at least 130 feet (40 meters) of sea water. Absolute Contraindications: • Asymmetric sepal hypertrophy and valvular stenosis • Congestive heart failure PULMONARY Asthma (reactive airway disease), COPD cystic or cavitating lung diseases all may lead to air trapping. Relative Contraindications: • History of... –prior asthma or reactive airway disease (RAD)* –exercise/cold induced bronchospasm (EIB) –solid, cystic or cavitating lesion • Pneumothorax secondary to: thoracic surgery *, trauma or pleural penetration*, previous over inflation injury* • Restrictive Disease** (*Air Trapping must be excluded) (**Exercise Testing necessary) Absolute Contraindications: • History of spontaneous pneumothorax • Active RAD (asthma), EIB, COPD or history of the same with abnormal PFS or positive challenge • Restrictive diseases with exercise impairment GASTROINTESTINAL Relative Contraindications: • Peptic ulcer disease • Inflammatory bowel disease • Malabsorption states • Functional bowel disorders • Post gastrectomy dumping syndrome • Paraesophageal or hiatal hernia Absolute Contraindications: • High grade gastric outlet obstruction • Chronic or recurrent small bowel obstruction • Entrocutaneous fistulae that do not drain freely • Esophageal diverticula • Severe gastroesophageal reflux • Achalasia • Unrepaired hernias of the abdominal wall potentially containing bowel METABOLIC AND ENDOCRINOLOGICAL Relative Contraindications: • Hormonal excess or deficiency • Obesity • Renal insufficiency Absolute Contraindications: • Diabetics on Insulin therapy or oral anti-hypoglycemia medication PREGNANCY Absolute Contraindications: Venous gas emboli formed during decompression may result in fetal malformations. Diving is absolutely contraindicated during any state of pregnancy. HEMATOLOGICAL Relative Contraindications: • Sickle cell trait • Acute anemia Absolute Contraindications: • Sickle cell disease • Polycythemia • Leukemia ORTHOPEDIC Relative Contraindications: Chronic Back Pain Amputation Scoliosis - assess impact on pulmonary function Aseptic osteonecrosis BEHAVIORAL HEALTH Relative Contraindications: • History of –drug or alcohol abuse –previous psychotic episodes • Developmental delay Absolute Contraindications: • History of panic disorder • Inappropriate motivation for scuba training • Claustrophobia and agoraphobia • Active psychosis or while receiving psychotropic medications • Drug or alcohol abuse BIBLIOGRAPHY The Physiology and Medicine of Diving, 4th edition, 1993; Diving and Subaquatic Medicine, 3rd edition 1994; Diving Physiology in Plain English, 2nd edition, 1997 rev. 1-04 CONTRAINDICATIONS TO DIVING

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