Canadian Association of Freediving and Apnea
MEDICAL STATEMENT – READ CAREFULLY
Please read this document carefully before signing it. This is a statement in which you are informed of some of the potential risks associated with free diving. To free dive safely, you must be in good physical condition, without any respiratory, circulatory or heart conditions present. Free diving is a physically strenuous activity.
Please answer each question with a YES or NO answer. Any YES answers require the approval of a physician before participation in free diving activities.
| _____ | Pregnant? |
| _____ | Neurological conditions – history or present condition of seizures, epilepsy, convulsions, strokes, black outs, sever migraines, aneurysm or taking medicine to prevent any of these? |
| _____ | Cardiovascular conditions – history or present condition of heart attack, heart surgery, hypertension, angina or taking medicine to prevent any of these? |
| _____ | Pulmonary conditions – history or present condition of collapsed lung (pheumothorax), lung disease, lung cysts, emphysema, breathing difficulties, asthma, wheezing disorders or taking medication to prevent any of these? |
| _____ | Ears/Sinus – history or present condition of permanent holes in the eardrums, ruptured eardrum, hearing loss, cysts in sinus cavity, persistent sinus infections, inability to equalize ears, problems with balance or taking medication to prevent any of these? |
| _____ | Diabetic – history or present condition of diabetes or taking medication to prevent this? |
| _____ | OTHER – Any medical disorders or conditions that would impact your personal safety from performing strenuous exercise in the water? |
| __________________________________ | _________________ |
| Signature | Date |
| __________________________________ | _________________ |
| Signature of parent or guardian (if under 18 years of age) |
Date |
| __________________________________ | _________________ |
| Address | Phone |
| Updated 27 September 2001 | Home -> Administration -> Forms |