Medical Statement

	UCI Medical Statement Please read carefully! The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in UCI dive training. UCI dive training is strenuous and requires good physical conditioning. Public Safety Diving requires a level of physical fitness beyond that of sport divers and therefor requires participants to maintain a state of physical readiness. A positive response to a question does not necessarily disqualify you from participating. 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. Name Address Course you want to take Please answer the following questions on your past or present medical history with a YES or NO. 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 the UCI program. If you answer YES to one of these questions and need a physical, UCI can supply you with a PADI Medical Statement and Guidelines for Physical Examination to take to your physician (this information is linked at the bottom of this page). All UCI students will fill out a Medical Statement during registration the first day of class, if you answer YES to any of the below questions, you must have a recent physical from you physician stating that you are able to take the UCI training.
	Could you be pregnant or are you attempting to become pregnant? Do you regularly take prescription or nonprescription medications?(with the exception of birth control) Are you over 45 years of age and have one or more of the following? currently smoke a pipe, cigars, or cigarettes have a high cholesterol level have a family history of heart attacks or strokes Have you ever had or do you currently have ... Asthma, or wheezing with breathing, or wheezing with exercise? Frequent or severe attacks of hayfever or allergy? Frequent colds, sinusitis or bronchitis? Any form of lung disease? Pneumothorax (collapsed lung)? History of chest surgery? Claustrophobia or agoraphobia (fear of closed or open spaces)? Behavioral health problems? Epilepsy, seizures, convulsions or take medications to prevent them? Recurring migraine headaches or take medications to prevent them? History of blackouts or fainting (full/partial loss of consciousness)? Do you frequently suffer from motion sickness (seasick, carsick, etc.)? History of diving accidents or decompression sickness? History of recurrent back problems? History of back surgery? History of diabetes? History of back, arm or leg problems following surgery, injury or fracture? Inability to perform moderate exercise (example: walk one mile within 12 minutes)? History of high blood pressure or take medicine to control blood pressure? History of any heart disease? History of heart attacks? Angina or heart surgery or blood vessel surgery? History of ear or sinus surgery? History of ear disease, hearing loss or problems with balance? History of problems equalizing (popping) ears with airplane or mountain travel? History of bleeding or other blood disorders? History of any type of hernia? History of ulcers or ulcer surgery? History of colostomy? History of drug or alcohol abuse?

		Important Note: If you need to get a dive physical from a medical doctor due to answering "Yes" to any of the above questions and you would like to print a copy of the PADI Medical Statement, click on this link: "PADI Medical Statement" and then hit print.