Merak Diving | Diver Registration

DNI, NIE, CIF,Passport*

Name and surname*
*

Birth date*

Telephone*
*

Email*
*

Language

What activity are you going to do?.

Dive Try scuba diving Open Water Course ADV Course Specialty Course

Date of Activity or Start Date of Activities*

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 of these 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.References to "diving" on this form encompass both recreational scuba 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.

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.

	Answer all questions YES or NO
1	I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.	YES	NO
	Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.	YES	NO
	Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.	YES	NO
	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.	YES	NO
	Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.	YES	NO
	Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.	YES	NO
2	I am over 45 years of age.	YES	NO
	I currently smoke or inhale nicotine by other means.	YES	NO
	I have a high cholesterol level.	YES	NO
	I have high blood pressure.	YES	NO
	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 disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).	YES	NO
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 12 months.	YES*	NO
4	I have had problems with my eyes, ears, or nasal passages/sinuses.	YES	NO
	Sinus surgery within the last 6 months.	YES	NO
	Ear disease or ear surgery, hearing loss, or problems with balance.	YES	NO
	Recurrent sinusitis within the past 12 months.	YES	NO
	Eye surgery within the past 3 months.	YES	NO
5	I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.	YES*	NO
6	I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.	YES	NO
	Head injury with loss of consciousness within the past 5 years.	YES	NO
	Persistent neurologic injury or disease.	YES	NO
	Recurring migraine headaches within the past 12 months, or take medications to prevent them.	YES	NO
	Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.	YES	NO
	Epilepsy, seizures, or convulsions, OR take medications to prevent them.	YES	NO
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 or developmental disability.	YES	NO
	Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.	YES	NO
	Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.	YES	NO
	Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.	YES	NO
	An addiction to drugs or alcohol requiring treatment within the last 5 years.	YES	NO
8	I have had back problems, hernia, ulcers, or diabetes.	YES	NO
	Recurrent back problems in the last 6 months that limit my everyday activity.	YES	NO
	Back or spinal surgery within the last 12 months.	YES	NO
	Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.	YES	NO
	An uncorrected hernia that limits my physical abilities.	YES	NO
	Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.	YES	NO
9	I have had stomach or intestine problems, including recent diarrhea.	YES	NO
	Ostomy surgery and do not have medical clearance to swim or engage in physical activity.	YES	NO
	Dehydration requiring medical intervention within the last 7 days.	YES	NO
	Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.	YES	NO
	Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).	YES	NO
	Active or uncontrolled ulcerative colitis or Crohn’s disease.	YES	NO
	Bariatric surgery within the last 12 months.	YES	NO
10	I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).	YES*	NO

Fecha de la versión: 01-02-2022 SSI

If you answered NO to the 10 previous questions, is not required a medical evaluation. Please, read and accept the following participant statement with the date and your signature.

Participant statement: I answered all the questions honestly and I understand that I accept the responsibility for any consequence resulting from any question that I could have answered inaccurately or any current or past health condition that I didn’t reveal.

Signature of the participant (or if the person is a minor, it’s required the signature of the participant’s parent/guardian).

Name of parent/guardian in case of minor

Date 26/07/2026

Instructor: Xavier Boqué Arguemí. Dive Center: Merak Diving

* If you answered YES to the previous questions 3, 5 or 10 or any of the questions of the page 2, read and accept the previous statement with the date and signature and bring the Medical Evaluation form to your doctor for a medical evaluation. The participation in a diving program requires the evaluation and approval of your doctor.