Diving Medical Form Page

Diving Medical Assessment

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Diving Medical Assessment Form

Diving Medical Declaration Questionaire & Clinical Examination Form

Personal Details

Name *

First

Middle

Last

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

(Country Code) -space- (Area Code) -space-(XXX XXXXX)

Mobile / Cellular Phone *

(Country Code) -space- (Area Code) -space-(XXX XXXXX)

Email *

D.O.B *

dd-mm-yyyy

Gender *

Select Gender

Passport Number *

Passport #

Singapore NRIC / FIN Number *

This field must be filled if the Diving MEdical is SS511

Type of Diving *

Type of Diver *

Diving / Compressed Air Exposure Status *

Trainee - Occupational Diver
Freelance - Occupational Diver
Employee - Occupational Diver
Trainee - Recreational Diver
Leisure - Recreational Diver ( non-trainee)
Pre-Dive Check - Recreational
Trainee Compressed Airwork (MOM)
Employee Compressed Airwork (MOM)
Employee CAW (Man & Medical Lock Operator)
Volunteer Diver - Occupational
Other

Training School Name *

For All Divers or Potential Diver undergoing instruction

Training School Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

For All Divers or Potential Diver undergoing instruction

Employer Company Name *

To be filled out if Diver is Employed by a Company

Employer Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

To be filled out if Diver is Employed by a Company

Category of Diving Medical *

SS511
IMCA
AS2299
SPF - Singapore Police FOrce
CAW - Compressed Airworks
SPUMS -Recreational SCUBA
Thailand Diving Medical
Indonesian Diving Medical
Hyperbaric Medical (Medical Staff)
Other

Category of Diving Medical - Other: *

Fill in the Name/Type of Medical required

Medical Type *

Diving Medical
Diving Technician
Diving Life Support Technician
Topside Medical Only
Hyperbaric Medical (Medical Staff)
Bounce Dive Medical
CAW - MOM Guidelines
CAW - Man Lock Operator
CAW - Medical Lock Operator
Others

Medical Type- Others: *

Fill in the Name/Type of Medical required

Medical Classification *

Initial
Renewal
Periodic
Return to Diving
Others

Medical Classification - Others: *

Type of Diving - Occupational or Recreational *

Air Diving
Mixed Gas Diving
Saturation Diving
Recreational Diving
Tunnelling
Other

Recreational Diving

Open Water / Advance Training
Dive Master Training
Assistant Instructor Training
Instructor Training
Rebreather Training
Other

Recreational Diving - Other: *

Fill in what sort of Recreational Diving you are doing

Recreational Diving Certifying Agency *

PADI
NAUI
SSI
GUE
TDI
IANTD
Other

Recreational Diving Certifying Agency - Other: *

Fill in the Certifying Agency

Do you have any medical conditions or surgical conditions or operations? *

Type Medical or Surgical conditions or operation :

Describe the conditions / Operations- Year occurred , The Condition/Operation , Where was it diagnosed / performed etc

Smoking

Have you ever smoked? *

Are you currently still smoking? *

Have you smoked within the past 20 years? *

What year did you start smoking? *

Which year did you stop smoking? *

How much did you smoke? (sticks/day) *

What do / have you smoked? *

Others: *

Please Describe

Alcohol

Do you drink alcohol? *

What type of alcohol do you mainly drink *

Others

What other forms of Alcohol do you drink

How much alcohol do you drink per week? e.g. Beer (Cans/Bottles/Standard Drink), Wine (Glasses/Bottles), Spirits (Glasses/Bottles) *

When do you drink? *

Sleepiness Scale

Sitting & Reading *

Watching TV

Sitting inactive in a public place e.g. theater/meeting

As a passenger in a car for >1hr

Lying to rest in the afternoon

Sitting and talking to someone

Sitting quietly after lunch

In a car while stopped for a few mins in traffic

Medical Declaration

Do you currently/previously have or have experienced any of the below:

Since your previous Diving Medical, do you have any of the below:

Have you been unwell in the last 12 months?

Please describe the nature of the medical condition(s) : *

Have you been on Medical Sick Leave in the last 12 months? *

No. of Days of Medical Sick Leave have you taken in the last 12 months *

No. of Days you did not dive due to Sickness in the last 12 months *

Diving Medical in the Past

Prescription Spectacles

Contact Lenses

Eye or Visual Problem

Dentures or Plate

Recent Dental Procedure

Hay Fever

Sinusitis

Nosebleeds

Deafness or ringing noises in the ear

Ear infection or discharge from the ear

Giddiness or loss of balance

Operation on the ear

Other ear, nose or throat problem

Severe motion sickness

Migraine

Fainting or blackouts

Convulsions, fits or epilepsy

Unconsciousness

Head injury or concussion

Sleepwalking

Severe depression

Claustrophobia

Mental illness

Heart disease

Abnormal blood test

ECG

Palpitations or consciousness of your heartbeat

High Blood Pressure

Rheumatic Fever

Shortness of breath on exertion

Bronchitis or Pneumonia

Pleurisy or severe chest pain

Coughing up blood or phelgm

Chronic or persistent cough

Pneumothorax

Frequent chest colds or flu

Asthma or wheezing

Need to use a puffer or inhaler

Operation on the chest, lungs or heart

Other chest complaints

Vomiting blood or passing red or black bowel motions

Recurrent vomiting or diarrhea

Jaundice, hepatitis or liver disease

Malaria or other tropical disease

Hernia or rupture

Back injury

Significant joint problem or sports injury

Limitation of movement

Fracture

Paralysis or muscle weakness

Kidney or bladder disease

Diabetes

Sickle cell disease

Bleeding problem or other blood disease

Skin disease

Contagious disease

Operation

Admitted to hospital

Rejected for life insurance

Failed a medical examination

Unable to work on medical grounds

Any other illness or health problem

Family history of heart disease

Family history of asthma or chest disease

Females Only

Are you now pregnant or planning to be

Do you have periods which incapacitate you or which may reduce your physical or mental performance

Diving History To Date

Approx. date of first compress air dive

Total hours under pressure

Types of diving experience

Scuba Air
Surface Supply
Saturation
Scuba Mix Gas
Surface Deco
Oxygen
Hookah
Bell Diving

How many dives to date

Longest Dive

Deepest Dive

Have you ever suffered from ear squeeze

Have you ever suffered from sinus squeeze

Have you ever suffered from decompression illness

Have you ever suffered from headaches during or after dive

Have you ever suffered from extreme tiredness dive

Any other diving-related problems?

I declare that the answers given above are true of my belief and that to the best of my knowledge they are complete and correct. I give permission for the result of this examination to be revealed to other doctors who examine me and to my employer/company in which I gain employment. I further declare that i have NOT witheld any relevant information or made any misleading statement.

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Personal Details

Smoking

Alcohol

Sleepiness Scale

Medical Declaration

Do you currently/previously have or have experienced any of the below:

Since your previous Diving Medical, do you have any of the below:

Females Only

Diving History To Date

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