December 21, 2014

APPENDIX 1 Diving Medical Exam Overview For The Examining Physician

This person, _____________________, requires a medical examination to assess their fitness for certification as a Scientific Diver for the_______________________ (Organizational Member). Their answers on the Diving Medical History Form (attached) may indicate potential health or safety risks as noted. Your evaluation is requested on the attached scuba Diving Fitness Medical Evaluation Report. If you have questions about diving medicine, you may wish to consult one of the references on the attached list or contact one of the physicians with expertise in diving medicine whose names and phone numbers appear on an attached list, the Undersea Hyperbaric and Medical Society, or the Divers Alert Network. Please contact the undersigned Diving Safety Officer if you have any questions or concerns about diving medicine or the __________________________ standards. Thank you for your assistance. Organizational Member

______________________________________ _____________________________
Diving Safety Officer Date
______________________________________ _____________________________
Printed Name Phone Number

Scuba and other modes of compressed-gas diving can be strenuous and hazardous. A special risk is present if the middle ear, sinuses, or lung segments do not readily equalize air pressure changes. The most common cause of distress is eustachian insufficiency. Recent deaths in the scientific diving community have been attributed to cardiovascular disease. Please consult the following list of conditions that usually restrict candidates from diving.

(Adapted from Bove, 1998: bracketed numbers are pages in Bove)

CONDITIONS WHICH MAY DISQUALIFY CANDIDATES FROM DIVING
1. Abnormalities of the tympanic membrane, such as perforation, presence of a monomeric membrane, or inability to autoinflate the middle ears. [5 ,7, 8, 9]
2. Vertigo, including Meniere’s Disease. [13]
3. Stapedectomy or middle ear reconstructive surgery. [11]
4. Recent ocular surgery. [15, 18, 19]
5. Psychiatric disorders including claustrophobia, suicidal ideation, psychosis, anxiety states, untreated depression. [20 – 23]
6. Substance abuse, including alcohol. [24 – 25]
7. Episodic loss of consciousness. [1, 26, 27]
8. History of seizure. [27, 28]
9. History of stroke or a fixed neurological deficit. [29, 30]
10. Recurring neurologic disorders, including transient ischemic attacks. [29, 30]
11. History of intracranial aneurysm, other vascular malformation or intracranial hemorrhage. [31]
12. History of neurological decompression illness with residual deficit. [29, 30]
13. Head injury with sequelae. [26, 27]
14. Hematologic disorders including coagulopathies. [41, 42]
15. Evidence of coronary artery disease or high risk for coronary artery disease. [33 – 35]
16. Atrial septal defects. [39]
17. Significant valvular heart disease – isolated mitral valve prolapse is not disqualifying. [38]
18. Significant cardiac rhythm or conduction abnormalities. [36 – 37]
19. Implanted cardiac pacemakers and cardiac defibrillators (ICD). [39, 40]
20. Inadequate exercise tolerance. [34]
21. Severe hypertension. [35]
22. History of spontaneous or traumatic pneumothorax. [45]
23. Asthma. [42 – 44]
24. Chronic pulmonary disease, including radiographic evidence of pulmonary blebs, bullae, or cysts. [45,46]
25. Diabetes mellitus. [46 – 47]
26. Pregnancy. [56]

SELECTED REFERENCES IN DIVING MEDICINE
Available from Best Publishing Company, P.O. Box 30100, Flagstaff, AZ 86003-0100, the Divers Alert Network (DAN) or the Undersea and Hyperbaric Medical Society (UHMS), Durham, NC

á       Elliott, D.H. ed. 1996.  Are Asthmatics Fit to Dive?  Kensington, MD: Undersea and Hyperbaric Medical Society.

á       Bove, A.A. 2011. The cardiovascular system and diving risk. Undersea and Hyperbaric Medicine 38(4): 261-269.

á       Thompson, P.D. 2011. The cardiovascular risks of diving. Undersea and Hyperbaric Medicine 38(4): 271-277.

á       Douglas, P.S. 2011. Cardiovascular screening in asymptomatic adults: Lessons for the diving world. Undersea and Hyperbaric Medicine 38(4): 279-287.

á       Mitchell, S.J., and A.A. Bove. 2011. Medical screening of recreational divers for cardiovascular disease: Consensus discussion at the Divers Alert Network Fatality Workshop. Undersea and Hyperbaric Medicine 38(4): 289-296.

á       Grundy, S.M., Pasternak, R., Greenland, P., Smith, S., and Fuster, V. 1999. Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations. AHA/ACC Scientific Statement. Journal of the American College of Cardiology, 34: 1348-1359.  http://content.onlinejacc.org/cgi/content/short/34/4/1348

á       Bove, A.A. and Davis, J.  2003. DIVING MEDICINE, Fourth Edition. Philadelphia: W.B. Saunders Company.

á       Edmonds, C., Lowry, C., Pennefather, J. and Walker, R. 2002.  DIVING AND SUBAQUATIC MEDICINE, Fourth Edition. London: Hodder Arnold Publishers.

á       Bove, A.A. ed. 1998. MEDICAL EXAMINATION OF SPORT SCUBA DIVERS, San Antonio, TX: Medical Seminars, Inc.

á       NOAA DIVING MANUAL, NOAA. Superintendent of Documents. Washington, DC: U.S. Government Printing Office.

á       U.S. NAVY DIVING MANUAL. Superintendent of Documents, Washington, DC: U.S. Government Printing Office, Washington, D.C.

APPENDIX 2 AAUS MEDICAL EVALUATION OF FITNESS FOR SCUBA DIVING REPORT
___________________________________________________________________________________________
Name of Applicant (Print or Type) Date of Medical Evaluation (Month/Day/Year)

To The Examining Physician: Scientific divers require periodic scuba diving medical examinations to assess their fitness to engage in diving with self-contained underwater breathing apparatus (scuba). Their answers on the Diving Medical History Form may indicate potential health or safety risks as noted. Scuba diving is an activity that puts unusual stress on the individual in several ways. Your evaluation is requested on this Medical Evaluation form. Your opinion on the applicant’s medical fitness is requested. Scuba diving requires heavy exertion. The diver must be free of cardiovascular and respiratory disease (see references, following page). An absolute requirement is the ability of the lungs, middle ears and sinuses to equalize pressure. Any condition that risks the loss of consciousness should disqualify the applicant. Please proceed in accordance with the AAUS Medical Standards (Sec. 6.00). If you have questions about diving medicine, please consult with the Undersea Hyperbaric Medical Society or Divers Alert Network.

TESTS: THE FOLLOWING TESTS ARE REQUIRED:

DURING ALL INITIAL AND PERIODIC RE-EXAMS (UNDER AGE 40):

á       Medical history

á       Complete physical exam, with emphasis on neurological and otological components

á       Urinalysis

á       Any further tests deemed necessary by the physician

ADDITIONAL TESTS DURING FIRST EXAM OVER AGE 40 AND PERIODIC RE-EXAMS (OVER AGE 40):

á       Chest x-ray (Required only during first exam over age 40)

á       Resting EKG

á       Assessment of coronary artery disease using Multiple-Risk-Factor Assessment1 

(age, lipid profile, blood pressure, diabetic screening, smoking)

Note: Exercise stress testing may be indicated based on Multiple-Risk-Factor Assessment2

PHYSICIAN’S STATEMENT:

              01   Diver IS medically qualified to dive for:                                  2 years (over age 60)

                                                                                                            3 years (age 40-59)

                                                                                                            5 years (under age 40)



              02   Diver IS NOT medically qualified to dive:                    Permanently             Temporarily.

I have evaluated the abovementioned individual according to the American Academy of Underwater Sciences medical standards and required tests for scientific diving (Sec. 6.00 and Appendix 1) and, in my opinion, find no medical conditions that may be disqualifying for participation in scuba diving. I have discussed with the patient any medical condition(s) that would not disqualify him/her from diving but which may seriously compromise subsequent health. The patient understands the nature of the hazards and the risks involved in diving with these conditions.

____________________________________________________ MD or DO _______________________________
Signature Date

__________________________________________________________________________________________
Name (Print or Type)

_____________________________________________________________________________________________
Address

__________________________________ ________________________________________________________
Telephone Number E-Mail Address

My familiarity with applicant is: _____This exam only _____Regular physician for _______ years

My familiarity with diving medicine is: ________________________________________________________________

APPENDIX 2b
AAUS MEDICAL EVALUATION OF FITNESS FOR SCUBA DIVING REPORT
APPLICANT’S RELEASE OF MEDICAL INFORMATION FORM

_______________________________________________________________________________________________
Name of Applicant (Print or Type)

I authorize the release of this information and all medical information subsequently acquired in association with my diving to the _____________________________________ Diving Safety Officer and Diving Control Board or their designee at (place) __________________________________________ on (date) ______________________________

Signature of Applicant __________________________________________________ Date_____________________

REFERENCES

1 Grundy, S.M., Pasternak, R., Greenland, P., Smith, S., and Fuster, V. 1999. Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations. AHA/ACC Scientific Statement. Journal of the American College of Cardiology, 34: 1348-1359. http://content.onlinejacc.org/cgi/content/short/34/4/1348

APPENDIX 3 DIVING MEDICAL HISTORY FORM
(To Be Completed By Applicant-Diver)

Name ______________________________________ Sex ____ Age ___ Wt.___ Ht. ___

Sponsor ____________________________________________ Date ___/___/___
(Dept./Project/Program/School, etc.) (Mo/Day/Yr)

TO THE APPLICANT:
Scuba diving places considerable physical and mental demands on the diver. Certain medical and physical requirements must be met before beginning a diving or training program. Your accurate answers to the questions are more important, in many instances, in determining your fitness to dive than what the physician may see, hear or feel as part of the diving medical certification procedure.

This form shall be kept confidential by the examining physician. If you believe any question amounts to invasion of your privacy, you may elect to omit an answer, provided that you shall subsequently discuss that matter with your own physician who must then indicate, in writing, that you have done so and that no health hazard exists.

Should your answers indicate a condition, which might make diving hazardous, you will be asked to review the matter with your physician. In such instances, their written authorization will be required in order for further consideration to be given to your application. If your physician concludes that diving would involve undue risk for you, remember that they are concerned only with your well-being and safety.



 

Yes

No

Please indicate whether or not the following apply to you

 

Comments



 

1



 



 

Convulsions, seizures, or epilepsy



 

2



 



 

Fainting spells or dizziness



 

3



 



 

Been addicted to drugs



 

4



 



 

Diabetes



 

5



 



 

Motion sickness or sea/air sickness



 

6



 



 

Claustrophobia



 

7



 



 

Mental disorder or nervous breakdown



 

8



 



 

Are you pregnant?



 

9



 



 

Do you suffer from menstrual problems?



 

10



 



 

Anxiety spells or hyperventilation



 

11



 



 

Frequent sour stomachs, nervous stomachs or vomiting spells



 

12



 



 

Had a major operation



 

13



 



 

Presently being treated by a physician



 

14



 



 

Taking any medication regularly (even  non-prescription)



 

15



 



 

Been rejected or restricted from sports



 

16



 



 

Headaches (frequent and severe)



 

17



 



 

Wear dental plates



 

18



 



 

Wear glasses or contact lenses



 

19



 



 

Bleeding disorders



 

20



 



 

Alcoholism



 

21



 



 

Any problems related to diving



 

22



 



 

Nervous tension or emotional problems



 

Yes

No

Please indicate whether or not
the following apply to you

Comments



 

23



 



 

Take tranquilizers



 

24



 



 

Perforated ear drums



 

25



 



 

Hay fever



 

26



 



 

Frequent sinus trouble, frequent drainage from the nose, post-nasal drip, or stuffy nose



 

27



 



 

Frequent earaches



 

28



 



 

Drainage from the ears



 

29



 



 

Difficulty with your ears in airplanes or on mountains



 

30



 



 

Ear surgery



 

31



 



 

Ringing in your ears



 

32



 



 

Frequent dizzy spells



 

33



 



 

Hearing problems



 

34



 



 

Trouble equalizing pressure in your ears



 

35



 



 

Asthma



 

36



 



 

Wheezing attacks



 

37



 



 

Cough (chronic or recurrent)



 

38



 



 

Frequently raise sputum



 

39



 



 

Pleurisy



 

40



 



 

Collapsed lung (pneumothorax)



 

41



 



 

Lung cysts



 

42



 



 

Pneumonia



 

43



 



 

Tuberculosis



 

44



 



 

Shortness of breath



 

45



 



 

Lung problem or abnormality



 

46



 



 

Spit blood



 

47



 



 

Breathing difficulty after eating particular foods, after exposure to particular pollens or animals



 

48



 



 

Are you subject to bronchitis



 

49



 



 

Subcutaneous emphysema (air under the skin)



 

50



 



 

Air embolism after diving



 

51



 



 

Decompression sickness



 

52



 



 

Rheumatic fever



 

53



 



 

Scarlet fever



 

54



 



 

Heart murmur



 

55



 



 

Large heart



 

56



 



 

High blood pressure



 

57



 



 

Angina (heart pains or pressure in the chest)



 

58



 



 

Heart attack



 

Yes

No

Please indicate whether or not
the following apply to you

Comments



 

59



 



 

Low blood pressure



 

60



 



 

Recurrent or persistent swelling of the legs



 

61



 



 

Pounding, rapid heartbeat or palpitations



 

62



 



 

Easily fatigued or short of breath



 

63



 



 

Abnormal EKG



 

64



 



 

Joint problems, dislocations or arthritis



 

65



 



 

Back trouble or back injuries



 

66



 



 

Ruptured or slipped disk



 

67



 



 

Limiting physical handicaps



 

68



 



 

Muscle cramps



 

69



 



 

Varicose veins



 

70



 



 

Amputations



 

71



 



 

Head injury causing unconsciousness



 

72



 



 

Paralysis



 

73



 



 

Have you ever had an adverse reaction to medication?



 

74



 



 

Do you smoke?



 

75



 



 

Have you ever had any other medical problems not listed? If so, please list or describe below;



 

76



 

Is there a family history of high cholesterol?



 

77



 

Is there a family history of heart disease or stroke?



 

78



 

Is there a family history of diabetes?



 

79



 

Is there a family history of asthma?



 

80



 

Date of last tetanus shot?

Vaccination dates?



 

Please explain any “yes” answers to the above questions.

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

I certify that the above answers and information represent an accurate and complete description of my medical history.

________________________________________________________________________________________

Signature Date

APPENDIX 4
RECOMMENDED PHYSICIANS WITH EXPERTISE IN DIVING MEDICINE

List of local Medical Doctors that have training and expertise in diving or undersea medicine. Level I graduates of the Undersea Hyperbaric and Medical Society (UHMS) Fitness to Dive courses (approximately 250 physicians) are listed at http://membership.uhms.org/?page=DivingMedical (UHMS website, go to Resources, go to Library, go to Diving Medical Examiners)

1. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone
 

2. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone
 

3. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone
 
 

4. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone


5. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone

APPENDIX 6 SELECTED REFERENCES IN DIVING MEDICINE  

DIVING MEDICINE, 1990.  A. Bove and J. Davis.  W.B. Saunders Company, Philadelphia

DIVING AND SUBAQUATIC MEDICINE, Third Edition, 1992.  C. Edmonds, C. Lowery and J. Pennefather.  Butterworth-Heinemann Ltd.  Oxford.  (Available from Best Publishing Company, P.O. Box 30100, Flagstaff, AZ 86003-0100)
 

MEDICAL EXAMINATION OF SPORT SCUBA DIVERS,  Jefferson Davis, M.D. (ed.). Best Publishing Company, P.O. Box 30100, Flagstaff, AZ 86003-0100.
 

NOAA DIVING MANUAL,  NOAA. Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.
 

SCUBA DIVING IN SAFETY AND HEALTH,  C.W. Deuker. Madison Publishing Associates, Diving Safety Digest, P.O. Box 2735, Menlo Park, CA 94026
 

THE PHYSICIAN’S GUIDE TO DIVING MEDICINE,  C.W. Shilling, C.B. Carlston and R.A. Mathias. Plenum Press, New York, NY (Available through the Undersea and Hyperbaric Medical Association, Bethesda, MD)
 

U.S. NAVY DIVING MANUAL. Superintendent of Documents, U.S. Government Printing Office, Washington, D.C.