Immersion Freediving: Medical Form

Performance Freediving International, Inc.

MEDICAL STATEMENT – READ CAREFULLY

**IMPORTANT – PLEASE READ **

Some pre-existing physical conditions may increase your risk of injury while taking part in Freediving activities. Because of this, PFI has developed the following questionnaire to make you aware of these conditions. Failure to address these conditions with a doctor prior to engaging in breath-hold diving activity may endanger your health as well as the safety of any person you may dive with.

MEDICAL QUESTIONNAIRE

Please read each question carefully and answer them by checking either YES or NO. Please explain any “yes” answers in the space provided at the bottom of this questionnaire. This form and your answers will be kept confidential. A positive answer will not necessarily exclude you from participating in PFI endorsed events/competitions.

1.	NEUROLOGICAL CONDITIONS: Especially any history of seizure disorder, stroke, brain surgery, black out, severe migraine	headaches, vertigo or dizzy
episodes, significant head injury or aneurysm of the brain’s blood vessels.		___ YES ___ NO
2.	CARDIOVASCULAR CONDITIONS: Especially heart attack, heart surgery, irregular heart beat, uncontrolled elevated blood pressure (hypertension), heart
murmur, known PFO, acute pulmonary edema associated with swimming or diving.		___ YES ___ NO
3.	PULMONARY CONDITIONS: History of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, severe damage to lung
tissue, emphysema, or any lung problem which interferes with your ability to breathe.		___ YES ___ NO
4.	EAR CONDITIONS: Permanent holes of the eardrums, history of ruptured eardrum, permanent tubes in eardrums, severely	impaired hearing or hearing loss
in one or both ears, otis media, middle ear infection, severe surfers ear or major ear surgery.		___ YES ___ NO
5.	SINUS CONDITIONS: Tumor, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or persistent sinus infection.
		___ YES ___ NO

6. ASTHMA: History of asthma of asthma attacks. and/or use of an inhaler for control of wheezing.

Any history of wheezing caused by exercise, anxiety, cold, fatigue, etc. An condition requiring medication

___ YES ___ NO

7. DIABETES MELLITUS: Especially Type I Diabetes (Insulin dependent) or Type II Diabetes, which requires insulin or oral medication for control. Any form of Diabetes that is unstable, “brittle” or produces episodes of hypoglycemia (low blood sugar reactions), hyperglycemia (extremely high blood sugar with ketosis) or if there is related kidney disease, eye disease, heart disease or blood vessel disease. Also, of history of elevated blood sugar during pregnancy.

___ YES ___ NO

8.	PREGNANCY: If you are presently pregnant or planning to be pregnant.		___ YES ___ NO
9.	FREEDIVING/SCUBA DIVING CONDITIONS: Previous history of a diving accident, decompression sickness, decompression		___ YES ___ NO
of the inner ear of air embolus.
10.		MEDICATION: Any medication taken on a regular basis either over-the-counter or prescribed by a physician.	___ YES ___ NO
11.		GENERAL MEDICAL PROBLEMS: Any physical and/or emotional condition not mentioned that might effect your safety	___ YES ___ NO
in an underwater environment or affect your judgment under times of physical or emotional stress.

I certify that I have answered the above questions accurately and honestly.

Signed:______________________________________________________________Date:___________________________

Witnessed:___________________________________________________________Date:___________________________

________ Approved for Application

________ Requires Medical Clearance

________ Date

Doctors Name/Stamp: ______________________________________Doctors Signature: ______________________

My signature on the above verifies that I have completely reviewed this applicant’s medical form and find no counter-indications for recreational or competitive freediving