This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by (Instructors) Gabriel Lu, Conan Teng, WAiki Tang, Luis Torres, Manuel Chavez, Galvin Thomas Templar, Andy Rios, Norbert Lee, Megumi Itoh, Haruka Ito, Garrett Lu and (Facilities) Ocean Safari Scuba, Los Angeles County Park & Rec located in the city of San Gabriel, state of California
Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian.
Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks.
To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury.
You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.
If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing.
Divers Medical Questionnaire
To the Participant:
The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.
Please answer the following questions on your past or present medical history with a YES (Y) or NO (N). If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving.
If at any time during your dive training your medical condition changes, notify your NAUI Instructor immediately and complete a new Medical History Form.