의료 진술서 NovoScuba Medical StatementNovoScuba Medical StatementRecreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving.If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/ or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly. 먼저마지막이메일Date of BirthYour Course– Select –스쿠버 입문가이드 다이버오픈 워터 다이버다이빙 모험가다이브 익스플로러Better Buddy Diver구조 다이버다이브마스터다이브마스터 크로스오버Instructor Course강사 크로스오버딥 다이버DPV 다이버드리프트 다이버드라이 슈트 다이버멀티미디어 다이버내비게이션 다이버나이트 다이버나이트록스 다이버Underwater Moviemaker난파선 다이버Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women: If you are pregnant, or attempting to become pregnant, do not dive.I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I have/have had:Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease. 예 아니요Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise. 예 아니요A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. 예 아니요Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. 예 아니요Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance 예 아니요I am over 45 years of age 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I am over 45 years of age andI currently smoke or inhale nicotine by other means 예 아니요I have a high cholesterol level. 예 아니요I have high blood pressure. 예 아니요I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy) 예 아니요I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months. 예 아니요I have had problems with my eyes, ears, or nasal passages/sinuses. 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I have/have had:Sinus surgery within the last 6 months. 예 아니요Ear disease or ear surgery, hearing loss, or problems with balance. 예 아니요Recurrent sinusitis within the past 12 months. 예 아니요Eye surgery within the past 3 months. 예 아니요I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. 예 아니요I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I have/have had:Head injury with loss of consciousness within the past 5 years. 예 아니요Persistent neurologic injury or disease. 예 아니요Recurring migraine headaches within the past 12 months, or take medications to prevent them. 예 아니요Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. 예 아니요Epilepsy, seizures, or convulsions, OR take medications to prevent them. 예 아니요I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability. 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I have/have had:Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. 예 아니요Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. 예 아니요Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation 예 아니요An addiction to drugs or alcohol requiring treatment within the last 5 years. 예 아니요I have had back problems, hernia, ulcers, or diabetes. 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I have/have had:Recurrent back problems in the last 6 months that limit my everyday activity. 예 아니요Back or spinal surgery within the last 12 months. 예 아니요Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. 예 아니요An uncorrected hernia that limits my physical abilities. 예 아니요Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. 예 아니요I have had stomach or intestine problems, including recent diarrhea. 예 아니요You answered ‘yes’ to the question above, please complete these additional questions:I have/have had:Ostomy surgery and do not have medical clearance to swim or engage in physical activity. 예 아니요Dehydration requiring medical intervention within the last 7 days. 예 아니요Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. 예 아니요Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). 예 아니요Active or uncontrolled ulcerative colitis or Crohn’s disease. 예 아니요Bariatric surgery within the last 12 months. 예 아니요I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). 예 아니요 I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.Signature Sign Here I am over 18 years old 예 아니요이름성Parent or guardian signature required if under 18 years oldParent or Guardian’s First NameParent or Guardian’s Last NameSignature Sign Here Date / Time제출하기Save & Resume
