Screening Questions
1. Have you had any problems with your lungs, breathing, heart, and/or blood that affect your Yes* No*
2. Are you over 45 years old? Yes* No*
3. Do you find it difficult to perform moderate exercise or have had physical limitations in the last 12 Yes* No*
4. Have you had problems with your eyes, ears, or sinuses? Yes* No*
5. Have you had surgery in the last 12 months or complications from previous surgery? Yes* No*
6. Have you lost consciousness, suffered migraines, seizures, a stroke, or persistent neurological injury? Yes* No*
7. Have you had psychological problems, learning disorders, panic attacks, or addiction? Yes* No*
8. Have you had back problems, hernias, ulcers, or diabetes? Yes* No*
9. Have you had recent stomach or intestinal problems? Yes* No*
10. Are you taking prescription medications? (except birth control or malaria drugs other than Lariam-mefloquine) Yes* No*
If you answered YES to any question, please complete the Detailed Medical Assessment.
Detailed Medical Assessment
SECTION A – Respiratory and Cardiovascular Issues
Have you had chest, heart valve surgery, an implanted device, or chronic lung disease? Yes* No*
Have you had asthma, severe allergies, hay fever, or congested airways in the past 12 months? Yes* No*
Do you have any heart condition such as angina, heart failure, or arrhythmias? Yes* No*
Have you had recurrent bronchitis, persistent cough, or emphysema in the past 12 months? Yes* No*
SECTION B – Age-Related Risk Factors
Do you smoke or use nicotine in any form? Yes* No*
Do you have high cholesterol? Yes* No*
Do you have high blood pressure? Yes* No*
Do you have a family history of heart disease before age 50? Yes* No*
SECTION C – Eye, Ear, and Sinus Issues
Have you had sinus surgery in the past 6 months? Yes* No*
Have you had ear problems, hearing loss, or balance disorders? Yes* No*
Have you had recurrent sinusitis in the past 12 months? Yes* No*
Have you had eye surgery in the past 3 months? Yes* No*
SECTION D – Neurological Issues
Have you had a head injury with loss of consciousness in the past 5 years? Yes* No*
Have you had recurrent migraine headaches in the past 12 months? Yes* No*
Have you had epilepsy, seizures, or are taking medication for it? Yes* No*
SECTION E – Psychological Issues
Have you been diagnosed with depression, anxiety, panic attacks, or uncontrolled bipolar disorder? Yes* No*
Have you been diagnosed with a learning or developmental disorder that requires special attention? Yes* No*
Have you had addiction to drugs or alcohol in the past 5 years? Yes* No*
SECTION F – Back Problems, Hernias, and Diabetes
Have you had recurring back problems in the past 6 months? Yes* No*
Have you had back or spinal surgery in the past 12 months? Yes* No*
Do you have diabetes controlled by medication or diet? Yes* No*
SECTION G – Digestive Issues
Have you had ostomy surgery without medical clearance to swim? Yes* No*
Have you experienced dehydration requiring medical intervention in the past 7 days? Yes* No*
Do you have active Crohn’s disease or ulcerative colitis? Yes* No*
Fill out the PDF Medical Certificate if you answered yes to questions 3, 5, and/or 10 of the first survey, or yes to any of the questions in the second.Download
Confirmation
I confirm that I have answered all questions honestly and take responsibility for any inaccurate information.
Risk and Responsibility Statement/Non-Agency Acknowledgment Form – Diving Activities (EU Version)
Disclosure and Non-Agency Acknowledgment Agreement
I understand and agree that PADI® Members ("Members"), including Black Frog Divers , and/or any PADI Individual Instructor and Divemaster associated with the program in which I participate, are licensed to use various PADI trademarks and to conduct PADI training, but are not agents, employees, or franchisees of PADI EMEA Ltd., PADI Americas, Inc., or their parent, subsidiaries, or affiliated corporations ("PADI"). I further understand that Members' business activities are independent and not owned or operated by PADI, and that although PADI sets the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the day-to-day operation of Members' business activities or the supervision of divers by Members or their associated personnel.
Risk and Responsibility Statement
This statement informs you that you, as a certified diver or a student diver under the supervision of a certified instructor, are aware that scuba diving, freediving, and snorkeling have inherent risks, including those associated with boat travel to and from the dive site. This document also establishes that you participate in this diving experience at your own risk.
Your signature is required as proof that you have received, read, and understand this statement. It is important to read the contents before signing. If you do not understand anything contained here in, you should discuss it with your instructor. If you are a minor, this form must also be signed by a parent or guardian.
Warning
Scuba diving, freediving, and snorkeling all carry inherent risks that may result in serious injury or death.
Diving with compressed air involves specific inherent risks, including decompression sickness, embolism, or other hyperbaric injuries that may require treatment in a hyperbaric chamber. Diving with oxygen-enriched air ("enriched air") or other gas mixtures, including oxygen, involves specific risks, including oxygen toxicity and/or improper breathing gas mixtures. There are also risks of slipping or falling on board a vessel, being struck or cut by a vessel while in the water, injuries while boarding or exiting the vessel, and other hazards of the sea.
If diving from a boat, you must be present and attentive during the briefing by the boat staff. If you do not understand something, you will immediately notify the staff or the captain.
You must follow safe diving practices, planning no-decompression dives with parameters that allow for a safety stop before surfacing, and coming aboard with gas remaining in the cylinder as a safety precaution. If you encounter difficulties on the surface, you must immediately release your weights and inflate your BCD orally or with the low-pressure inflator to achieve positive buoyancy.
If a guide is present to assist during the dive and you choose to dive with the guide, it is your responsibility to remain near the guide throughout the dive.
Risk Acceptance
I understand and agree that neither the professionals conducting this program, nor the center through which this program is offered, Black Frog Divers , nor PADI EMEA Ltd., PADI Americas, Inc., nor their affiliates or subsidiary companies, nor any of their employees, officers, agents, contractors, or assigns accept any responsibility for death, injury, or loss that I may suffer due to my own conduct or any condition under my control that constitutes my own contributory negligence.
In the absence of negligence or other breach by the professionals conducting this program, the center that offers it, PADI EMEA Ltd., PADI Americas, Inc., and all of the aforementioned parties, my participation in this diving program is entirely at my own risk.
I HAVE BEEN FULLY INFORMED OF THE CONTENT OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT AND THE RISK AND LIABILITY STATEMENT BY READING THEM BEFORE SIGNING.
I have read, understand, and accept all the terms and conditions stated in this document.
Sign your form!
