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Respiratory diseases / Chest trauma / Pneumothorax / Chest / Perforated eardrum / Diabetes / Medicine / Health / Human anatomy


UNDERWATER WORLD SHARK DIVES MEDICAL DECLARATION To be completed and signed by resort diver Personal Details Surname Address Date of birth
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Document Date: 2012-12-11 03:01:02


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MedicalCondition

Yes No Breathlessness High blood pressure Other illness / Epilepsy Heart disease / nervous disorder Chest surgery Chronic bronchitis / kind Tuberculosis / water activities Any dizziness / persistent chest complaint Chronic / pneumothorax / Diabetes mellitus / doctor Yes No Ear surgery Fainting / Yes No Chronic / No Asthma / diabetes / seizures / /

MedicalTreatment

Ear surgery / oral contraceptives / Chest surgery / /

Person

Are / /

Position

resort diver / instructor / /

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