Llafranc (Girona)
T. +34 620 53 00 36
diving@tritonllafranc.com
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Each participant must complete the following information once per calendar year

Dive dates

Today is:
I come to dive the day:

Personal information

Gender:
Country:

Preferred language of communication:

Emergency contact

Dive information

Certification agency:
Dive certification:
Do you have a Nitrox certification?:

Number of logged dives:

Do you have an updated medical certificate for the practice of recreational diving? (less than one year at the time of the dives)

Diver Medical | Participant Questionnaire

Recreational 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 ofthese 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. Referencesto “diving” on thisform encompass both recreationalscuba 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.

DIRECTIONS

Complete 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.

Medical information

  1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. YesNo
    • Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung). YesNo
    • Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise. YesNo
    • A 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. YesNo
    • Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. YesNo
  2. I am over 45 years of age YesNo
    • I currently smoke or inhale nicotine by other means. YesNo
    • I have a high cholesterol level. YesNo
    • I have high blood pressure. YesNo
    • I 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 diseasebefore age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). YesNo
  3. I 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 12months YesNo
  4. I have had problems with my eyes, ears, or nasal passages/sinuses. YesNo
    • Sinus surgery within the last 6 months. YesNo
    • Ear disease or ear surgery, hearing loss, or problems with balance. YesNo
    • Recurrent sinusitis within the past 12 months. YesNo
    • Eye surgery within the past 3 months. YesNo
  5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. YesNo
  6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. YesNo
    • Head injury with loss of consciousness within the past 5 years. YesNo
    • Persistent neurologic injury or disease. YesNo
    • Recurring migraine headaches within the past 12 months, or take medications to prevent them. YesNo
    • Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. YesNo
    • Epilepsy, seizures, or convulsions, OR take medications to prevent them. YesNo
  7. I 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 disability YesNo
    • Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. YesNo
    • Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.. YesNo
    • Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care. YesNo
    • Una adicción a las drogas o al alcohol que requiere tratamiento en los últimos 5 años. YesNo
  8. I have had back problems, hernia, ulcers, or diabetes. YesNo
    • Recurrent back problems in the last 6 months that limit my everyday activity. YesNo
    • Back or spinal surgery within the last 12 months. YesNo
    • Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months. YesNo
    • An uncorrected hernia that limits my physical abilities. YesNo
    • Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. YesNo
  9. I have had stomach or intestine problems, including recent diarrhea YesNo
    • Ostomy surgery and do not have medical clearance to swim or engage in physical activity. YesNo
    • Dehydration requiring medical intervention within the last 7 days. YesNo
    • Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. YesNo
    • Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). YesNo
    • Active or uncontrolled ulcerative colitis or Crohn’s disease. YesNo
    • Bariatric surgery within the last 12 months. YesNo
  10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam). YesNo
I have honestly answered NO to all 10 questions above, a medical evaluation is not required.
I have answered YES to one or more of the above questions. I accept and understand that I will need to bring a medical certificate before coming to dive with Triton Diving.
  • 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.
  • I am of age: YesNo

Dive insurance information

Do you have your diving insurance up to date?
I understand that in Spain, it is mandatory, according to the ministerial order of November 22, 1997, that you must have diving insurance in force. Since I do not have up-to-date diving insurance, I will have to show it to the Triton Diving Center or sign a contract with Triton Diving Center on the first day of the diving activity.

Diving equipment information

Do you need to rent diving equipment?: (Wet or Dry Suit, Mask and Snorkel, Fins-with boots, BCD, Regulator, dive computer)
Neoprene wetsuit (Size)
Fins (Size)
Boots (Size )
Mask and snorkel
Jacket
Regulator
Dive computer
Upload the following files (Max. 5Mb): (Supported formats: pdf,jpg,jpeg,png)

  • Copy of your highest level of certification
  • Copy of your Nitrox certification
  • Copy of your medical certificate
  • Copy of your diving insurance
Privacy Policy:
The Triton Diving Center archives manager will use this information to respond to contact requests. The data sent will be saved on the server hosted within the EU. You can access, correct or delete them if you wish, by sending an email to diving@tritonllafranc.com.
Electronic signature:
Electronic signature of the Parent or Guardian

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