TO THE EXAMINING PHYSICIAN:

This person, (applicant for training)_____________________, requires a medical examination to assess his/her fitness for certification as a Diver for the (university)_______________________.  His /her 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.  Please contact the undersigned Diving Safety Officer if you have any questions or concerns about diving medicine or the (MBL Campus)__________________________ diving medical standards.  Thank you for your assistance.
 
______________________________________ ___________________
Signature of Diving Safety Officer   Date

______________________________________ ___________________
Diving Safety Officer's 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.  Most fatalities involve deficiencies in prudence, judgement, emotional stability or physical fitness.  Please consult the following list of conditions which usually restrict candidates from diving.

(Adapted from Davis 1986:47-50, bracketed numbers are pages in Davis)

1. Tympanic membrane perforation or aeration tube [7]
2. Inability to auto-inflate the middle ears [6,7,8]
3. External ear exostoses or osteomas adequate to prevent external ear canal pressure equilibration [4]
4. Meniere's Disease or other chronic vertiginous conditions, status post-surgery, such as subarachnoid endolymphatic shunt for Meniere's Disease [11]
5. Stapedectomy and middle ear prosthesis [9]
6. Chronic mastoiditis or mastoid fistula [5]
7. Any oral or maxillofacial deformity that interferes with the retention of the regulator mouthpiece [43]
8. Corrected near visual acuity not adequate to see tank pressure gauge, watch, decompression tables, and compass underwater.  Uncorrected visual acuity not adequate to see the diving buddy or locate the boat in case corrective lenses are lost underwater [13]
9. Radial keratotomy or other recent ocular surgery [14]
10 Claustrophobia of a degree to predispose to panic [15,16]
11. Suicidal ideation [16]
12. Significant anxiety states [16]
13. Psychosis [18]
14. Severe depression [16]
15. Manic states [16]
16. Alcoholism [19,20]
17. Mood-altering drug use [19,20]
18. Improper motivation for diving [16,17,18]
19. Episodic loss of consciousness [1,22]
20. History of seizure.  History of seizure in early childhood must be evaluated individually [21]
21. Migraine [20]
22. History of cerebrovascular accident or transient ischemic attack [23]
23. History of spinal cord trauma with neurologic deficit - whether fully recovered or not. [23]
24. Any degenerative or demyelinating CNS process [25]
25. Brain tumor with or without surgery [24]
26. Intracranial aneurysm or other vascular malformation [24]
27. History of neurological decompression sickness with residual deficit [23,24]
28. Head injury with sequelae [21]
29. History of intracranial surgery [24]
30. Sickle cell disease [34]
31. Polycythemia or leukemia [34]
32. Unexplained anemia [34]
33. History of myocardial infarction [28,29,20]
34. Angina or other evidence of coronary artery disease [29]
35. Unrepaired cardiac septal defects [32]
36. Aortic stenosis or mitral stenosis [32]
37. Complete heart block [31]
38. Fixed second-degree heart block [31]
39. Exercised-induced tachyarrhythmias [31,32]
40. Wolf-Parkinson-White (WPW) Syndrome with paroxysmal atrial tachycardia or syncope [31]
41. Fixed-rate pacemakers [33]
42. Any drugs which inhibit the normal cardiovascular response to exercise tolerance [31]
43. Peripheral vascular disease, arterial or venous, severe enough to limit exercise tolerance [33,41]
44. Hypertension with end-organ finding - retinal, cardiac, renal or vascular [30]
45. History of spontaneous pneumothorax [36]
46. Bronchial asthma.History of childhood asthma requires special studies [7,35]
47. Exercise or cold air-induced asthma [36,37]
48. X-ray evidence of pulmonary blebs, bullae, or cysts [36,37]
49. Chronic obstructive pulmonary disease [37]
50. Insulin-dependent diabetes mellitus. Diet or oral medication-controlled diabetes mellitus if there is a history of hypoglycemic episodes [38]
51. Any abdominal wall hernia with potential for gas-trapping until surgically corrected [41]
52. Paraesophageal or incarcerated sliding hiatal hernia [39]
53. Sliding hiatus hernia if symptomatic due to reflux esophagitis [39]
54. Pregnancy [1,45]
55. Osteonecrosis.  A history consistent with a high risk of dysbaric osteonecrosis
56. Any condition requiring ingestion of the following medication: antihistamines, bronchodilators, steroids, barbiturates, phenytoin, mood-altering drugs, insulin
______________________________________________________________________________

Attachments:   Medical Evaluation of Fitness for Scuba Diving Report
 Diving Medical History Form
 Question Evaluations for Diving Medical History Form
 Recommended Physicians with Expertise in Diving/Undersea Medicine
 References on Diving Medicine

APPENDIX 2 MEDICAL EVALUATION OF FITNESS FOR SCUBA DIVING REPORT

___________________________________________ __________________________
 Name of Applicant (Print or Type)    Date(Mo/Day/Year)

To The PHYSICIAN:

This person is an applicant for training or is presently certified to engage in diving with self- contained underwater breathing apparatus (scuba).  This is an activity which puts unusual stress on the individual in several ways.  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.  An absolute requirement is the ability of the lungs, middle ear and sinuses to equalize pressure.  Any condition that risks the loss of consciousness should disqualify the applicant.

TESTS:  Please initial that the following tests were completed.
 

[ ] APPROVAL.  I find no medical condition(s) which I consider incompatible with diving.

[ ] NOT APPROVE.  This applicant has medical condition(s) which, in my opinion, clearly would constitute unacceptable hazards to health and safety in diving.

REMARKS:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
______________________

I have discussed the patient's medical condition(s) which would not seriously interfere with diving but which may seriously compromise subsequent health.  The patient understands the nature of the hazards and the risks involved in diving with these defects.

________________________________________ M.D. Date _____________________
Name (Print) ___________________________________________________________M.D.
Address __________________________________________________________________
Telephone ________________________________________________________________
 

My familiarity with applicant is:

[ ] With this exam only

[ ] Regular Physician for _____ years

[ ] Other (describe) _____________________________________________________

 __________________________________________________________________

My familiarity with diving medicine:

[ ] On attached list of physicians

[ ] Other (describe) _____________________________________________________

 __________________________________________________________________

 __________________________________________________________________
 
 

----------------------------------------------------------------------------

APPLICANT'S RELEASE OF MEDICAL INFORMATION FORM

I authorize the release of this information and all medical information subsequently acquired in association with my diving to (MBL Campus)____________________________________________'s Diving Safety Officer and Diving Control Board or their designee.
 

Signature of Applicant ________________________________________ Date _______________

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

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

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

TO THE APPLICANT:

Scuba diving makes considerable demands on your physical and emotional condition.  Diving with particular defects amounts to asking for trouble not only for yourself, but to anyone coming to your aid if you get into difficulty in the water.  Therefore, it is prudent to meet certain medical and physical requirements before beginning a diving or training program.

Your answers to the questions are more important, in many instances, in determining your fitness than what the physician may see, hear or feel when you are examined.  Obviously, you should give accurate information or the medical screening procedure becomes useless.

This form shall be kept confidential.  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 and he/she 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, his/her 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 he/she is concerned only with your well-being and safety.  Respect the advice and the intent of this medical history form.
 

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

(Signature)________________________________________ (Date)_____________________

APPENDIX 4  MEDICAL HISTORY QUESTIONS EVALUATION FORM
 (Answer Screening Aid)  

  1 - A                  21 - B                  41 - A                 61 - B
  2 - B                  22 - B                  42 - B                 62 - B
  3 - B                  23 - B                  43 - B                 63 - B
  4 - B                  24 - C                  44 - B                 64 - B
  5 - C                  25 - B                  45 - B                  65 - B
  6 - B                  26 - B                  46 - B                  66 - B
  7 - B                  27 - B                  47 - B                  67 - B
  8 - A                  28 - B                  48 - B                  62 - B
  9 - B                  29 - B                  49 - B                  69 - B
10 - B                   30 - B                  50 - B                  70 - B
11 - B                   31 - B                  51 - B                  71 - B
12 - B                   32 - B                  52 - B                  72 - B
13 - B                   33 - B                  53 - B                  73 - C
14 - B                   34 - C                  54 - B                  74 - C
15 - B                   35 - B                  55 - B                  75 - B
16 - B                   36 - B                  56 - B
17 - C                   37 - B                  57 - A
18 - B                   38 - B                  58 - B
19 - B                   39 - B                  59 - B
20 - B                   40 - B                  60 - B
 

When a "Yes" answer is checked:

A = Absolute contraindication to diving;
B = Relative contraindication to diving, requires careful review by physician;
C = Of interest, not a contraindication.

APPENDIX 5 RECOMMENDED PHYSICIANS WITH EXPERTISE IN DIVING MEDICINE

List of local Medical Doctors that have training and expertise in diving or undersea medicine:

1. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone
 

2. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone
 

3. _____________________________________________________________
 Name
 _____________________________________________________________
 Address
 _____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________
 Telephone
 
 

4. _____________________________________________________________
 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.