HEALTH DECLARATION FORM / COVID-19

Read this statement prior to signing it. You must complete this additional medical questionnaire to enroll in a diver training program or to participate in any diving activities. If you are a minor, you must have this statement signed by your parent or guardian.

DIVER MEDICAL QUESTIONNAIRE

The purpose of this medical questionnaire is to ensure that you are medically fit to participate in diving and related activities. Please answer the following questions by checking (with an X ) YES or NO. If you are not sure, answer YES. A positive response means that there may be a preexisting condition that could affect your safety while diving. If any of these items apply to you, we must request that you consult with a physician, preferably a specialist in diving medicine, prior to participating in diving activities.

 

PLEASE NOTE

COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalesce before returning to full activities – a process that can take weeks or months depending on symptom severity (1).

MEDICAL RECOMMENDATIONS (2,3):

  • Divers who have tested positive with COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.
  • Divers who have had symptomatic COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a diving medicine specialist.
  • Divers who have been hospitalized with or because of pulmonary symptoms in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted or coordinated by a diving medicine specialist, with complete pulmonary function testing (at least FVC, FEV1, PEF25-50-75, RV and FEV1/FVC, and an exercise test with peripheral oxygen saturation measurement) as well as a high resolution CT scanning of the lungs.
  • Divers who have been hospitalized with or because of cardiac problems in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted or coordinated by a diving medicine specialist with cardiac evaluation, including echocardiography and exercise test (exercise electrocardiography).

 

(1) Return to Diving Post COVID-19 - issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.

(2) Diving after COVID-19 pulmonary infection. A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG).

(3) Recreational and professional diving after the Coronavirus disease (COVID-19) outbreak - Position statement of EUBS & ECHM

 

The Form has been developed by the DAN Europe Medical Division team, based on information available as of May 2020. The epidemiological situation is constantly evolving. As a result, this document may be subject to changes and updates

 

Who will be participating?

Adult  Children

Signee Information

Participant Information

Where signing for a child, all the details below should be in respect of the child.

Within the 40 days immediately preceding the date of this Health Declaration Form, have you:

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions. I also commit to inform AQUA TCI about any symptom that may occur after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

ADDITIONAL DECLARATIONS / COVID-19







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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.