Medical Form | FUN AZUL FLEET

MEDICAL QUESTIONNAIRE

The purpose of this Medical Questionnaire is to find out if you should take medical advice by your doctor before participating in diving and/or snorkeling. A positive response to a question does not necessarily disqualify you from participating in the cruise. 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 participating in the cruise.

Please answer the following questions on your past 3 years and present medical history with a YES or NO.Please make sure to answer all the questions.

*If you answer YES to any of the items, you are requested to submit a medical certificate from your doctor allowing you to participate in the cruise.

■Destination:
MALDIVESLA PAZSOCORRO

■Cruise Departure Date（yyyy/mm/dd）

■Ear disease (otitis media, otitis externa), hearing problems (difficulty in hearing, ear noises), or problems with balance (dizziness)?
Ear surgery?
NoYes

■Ear or sinus surgery?
NoYes

■Sinusitis (including empyema), bronchitis (acute, chronic or allergies),or frequent colds?
NoYes

■Pneumothorax (collapsed lung)?
NoYes

■Asthma (current) or emphysema or tuberculosis (in the past)?
NoYes

■Prescription medications(excluding contraceptives)?
NoYes

■Mental illness, anxiety disorder (including panic attack, claustrophobia, agoraphobia, or neurosis), or behavioral disorders (emotional instability or distractions) or have you been told that you are unable to act as a group?
NoYes

■Heart disease? Heart surgery or blood vessel surgery?
NoYes

■High cholesterol level or taking medicine to lower cholesterol?
NoYes

■High blood pressure or taking medicine to lower blood pressure?
NoYes

■Heart attack (current and past)?
NoYes

■Blood disease (anemia, easy to bleed, or high blood clotting factor) or blood disease (blood vessel blocked or bad blood vessels)?
Any surgeries related to the diseases?
NoYes

■Any endocrine diseases (diabetes, high blood sugar or thyroid disease)?
NoYes

■Epileptic fit or convulsions? Have you taken preventive medications?
NoYes

■Neck, spine, back, arm or leg problems and/or have you received treatments?
NoYes

■Chest pain, palpitation, unusual shortness of breath or discomfort during/after workout?
NoYes

■Internal/external surgery recently?
NoYes

■Decompression disorder (trauma caused by changes in atmospheric pressure to ear, paranasal sinus, or lung or decompression sickness and/or arterial gas embolism)? Or diving accident?
NoYes

■Have you had treatments in high pressure chamber due to decompression disorder or diving accident?
NoYes

■Have you been tested and resulted positive or false positive with the COVID-19 (or SARS-COV-2) test or have you been a potential carrier of COVID-19?
NoYes

■Are you suffering from any of the symptoms of possible COVID-19 such as high fever, a cough, exhaust, muscle pain, dyspnoea, sore throat, lung infection, headache, taste disorder or diarrhea,?
NoYes

■Have you been in close contact with a confirmed or suspected patient of COVID-19?
NoYes

■The information I have provided about my health condition is accurate to the best of my knowledge.
I affirm it is my responsibility to inform my instructor of any and all changes to my health condition at any time during my participation in cruise.
I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition, or any changes thereto.

I hereby certify that my health condition is adaptable to participate in the diving cruise after filling out the questionnaire.

■Name
First Name:
Middle Name:
Last Name:

■E-Mail address

Press SUBMIT button to send the questionnaire to FUN AZUL FLEET.
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