Last Name / First Name
Have you ever had? / Have you ever had?
Yes / No / Yes / No
epilepsy or seizures / urinary tract problems
dizziness or fainting spells / kidney stones
frequent headaches / blood or sugar in urine
migraines
head injury / arthritis
swollen or painful joints
eye problems / broken bones
ear, nose or throat problems / back injuries or pain
hearing loss or tinnitis
trouble equalizing your ears / nervous problems
chronic colds / claustrophobia
severe tooth or gum problems / anxiety, depression
sinusitis / insomnia
allergies or hay fever / speech problems
lung problems / skin problems
asthma or wheezing / endocrine problems
pneumothorax (collapsed lung) / tumours, growths, cancer
shortness of breath / frequent motion sickness
chronic cough
treatment for addictions
heart problems / venereal diseases, STDs, HIV/AIDS
high blood pressure / tuberculosis
palpitations (irregular heart rate)
pain or pressure in chest / Diving injuries
blood disorder
Women
stomach, liver or bowel problems / breast /gynecological problems
frequent indigestion
gallstones / Do you?
jaundice/hepatitis / smoke - how much
diabetes / take medications
hernias
hemorrhoids / What year did you start diving
Certifying agency
serious illnesses or injuries / Number of dives completed
operations / Last polio/tetanus vaccination
Please give details of all 'YES' answers on the back of this page
I certify that the above information is true and complete
signature / date
DIVING MEDICAL EXAMINATION / PAGE 2/3
Last Name / First Name
FUNCTIONAL ENQUIRY / date
normal / abnormal / (describe abnormalities)
Gen
H&N
RESP
CV
GI
GU
GYN
MSK
DERM
CNS
PSYC
PHYSICAL EXAMINATION
Build / [ ] slender / Ht / HR / Vision
[ ] medium / uncorrected / corrected / colour
[ ] heavy / Wt / BP / od / od
[ ]obese / os / os
normal / abnormal / (describe abnormalities)
GEN
H&N / fundi
perla
eom
tm
sinuses
nasal
dental
thyroid
RESP
BREASTS
CV / jvp
pulses
S1S2
murmers
varicosities
bruits
ABD / lkks
rectal / Diagnosis: / [ ] FIT
GU / [ ] UNFIT
MSK / upper
lower
spine / Page 3/3
CNS / CN II - XII
motor/sens
reflexes
DERM
PSYCH
MISC
Revised: July 2009
Notes:
DIVING MEDICAL EXAMINATION
INSTRUCTIONS FOR STUDENTS
- Attached is your copy of the DIVING MEDICAL EXAMINATION.
- If possible this medical examination should be completed by a “Diving” physician who is a member of the Undersea & Hyperbaric Medical Society (UHMS), Diver Alert Network, (DAN), or any other diving organization. A list of doctors who are member of UHMS is provided in this packet. If it is not possible to find a doctor from these organization any physician can administer the physical examination and we will forward their results to a doctor who is a member of an Underwater Diving Organization for final approval.
- All costs of this examination are the direct responsibility of the student. The MinnesotaCommercialDiverTrainingCenter will not pay for this exam. You are directly responsible for this cost.
- This examination must be completed and copies of all results must be sent to the MinnesotaCommercialDiverTrainingCenter at 712 Washington St.Brainerd, MN. 56401. It is essential that you do this as soon as possible so we will have time to send the copies to an Undersea Hyperbaric physician for approval prior to the date of the class you are planning to attend.
- Besides the medical exam form, please complete the “Diver History” form and mail that to us with the other completed medical exam forms. The Diver History form is a medical questionnaire. You must answer these questions truthfully to insure your safety and the safety of other students in the class. The results of the medical questionnaire and tests must meet the most recent minimum standards for commercial diving as recommended by the Undersea & Hyperbaric Medical Society.
- Medical exams not administered by a doctor who is a member of UHMS will receive final approval by a physician who is a member of UHMS after you submit them to us.
- If you have any questions or problems regarding the Diving Medical Examination, please call: Bill Matthies at (218) 829-5953.
- Students found to have falsified medical information may be withdrawn from our program.
DIVING MEDICAL EXAMINATION
INSTRUCTIONS FOR PHYSICIANS
- Attached is a copy of theDIVING MEDICAL EXAMINATION.
- It is preferable that the Diving Medical Examination is done by a “Diving Physician” meaning a Doctor who is a member of the Undersea & Hyperbaric Medical Society. In the event you have been asked to administer the physical exam, and you are not a member of UHMS, or a similar diving organization, you may still give the exam and submit it to us and we will forward your findings to a UHMS physician in our area for final approval.
- This examination must be completed and copies of all results, including X-rays, lab test, etc. must be either sent directly to the MinnesotaCommercialDiverTrainingCenter at 712 Washington St.Brainerd, MN. 56401, or given to the student to send to us.
- Please note that the students must be tested for immunity to Hepatitis A & B and vaccinated if not immune.
- The following X-ray projections are required: Postero, Anterior, and Lateral Projections of the CHEST. In particular any evidence of asthma, COPD, scarring or bullae is of critical importance.
- The results of the medical examination and tests must meet the most recent minimum standards for commercial diving, as recommended by the Undersea & Hyperbaric Medical Society. If you are not a UHMS physician, and not familiar with these requirements remember these forms will be reviewed by a physician who is a member of that society.
- All student medical files are safely stored. Absolute confidentiality and security is maintained. A release form is included with the medical examination form. At the completion of the program, a copy of the student’s medical file is returned to him/her for inclusion in their medical history with their next Hyperbaric Physician.
- The Diving Medical Examination and all required tests are considered a “Third party request” and not a benefit of the MinnesotaCommercialDiverTrainingCenter. All costs for this exam should be billed directly to the student.
- If you require any further information please contact: William Matthies at (218) 829-5953.
DIVING MEDICAL EXAMINATION
CONSENT FORM
I, ______.
Name of student
Authorize my examining physician:
Dr. ______.
Address: ______.
______.
______.
______.
and any physician, hospital or clinic to furnish any information of my medical record, to determine my medical fitness to dive, to:
The Medical Physician & Consultant for Diving & Hyperbaric Medicine
MinnesotaCommercialDiverTrainingCenter
712 Washington St.
Brainerd, MN56401
______. ______.
Printed name Printed name
______.
Signature Witness
______. ______.
Date Date
DIVING MEDICAL EXAMINATION
Name of Student:______
The above named student has been medically examined and tested for fitness for commercial diving. This medical examination has been conducted in accordance with Recommendations on Fitness to Dive, by the Undersea & Hyperbaric Medical Society.
Copies of the following are enclosed:
Normal Abnormal
[ ] [ ] 1. Physical examination
[ ] [ ] 2. Blood chemistry
[ ] [ ] 3. Hemoglobin
[ ] [ ] 4. Urinalysis
[ ] [ ] 5. 12 lead electrocardiogram
[ ] [ ] 6. Chest X-ray
[ ] [ ] 7. Hepatitis A & B status: Immunitation date:______
[ ] [ ] 8. Any other test your physician feels is necessary.
The above named person has been found:
[ [ Fit to dive for all conditions and climates of work for 24 months.
[ ] Unfit for diving
______Physician address & telephone number
Physicians – signature
______.
Physicians – name
______.
Date