American Dive Center
8092 West Sample Road
Coral Springs, FL 33065
954.346.0174
800.310.0174 Email
Dive South Florida!
Recreational Diver Training
Medical History Form
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 pre existing condition that may affect your safety while diving and you must
seek the advice of your physician.
Please answer the following questions on your past or present medical history with a check
mark. If you are not sure, check it. If any of these items apply to you, you must have
written approval from a physician prior to participating in scuba diving training.
Note: This is not an electronic form. Feel free to print this form for your own use. A
printed copy of this form may be used for the physician's review and approval if required.
Student Information
Name
Birth Date
Age
Mailing Address Line 1
Mailing Address Line 2
City
State
Zip
Home Phone
Business Phone
Physician Information
Physician
Clinic/Hospital
Mailing Address Line 1
Mailing Address Line 2
City
State
Zip
Business Phone
Business Fax
Physicians Impression
I find no medical conditions that I
consider incompatible with diving.
I am unable to recommend this individual
for diving.
