CBC / Oxygen Toxicity Near Drowning CO2 Toxicity Asphyxiation CO / /
IndustryTerm
chemicals / food / /
MedicalCondition
Injury Eye Surgery Hearing Loss Ear Disease / allergies / Any Sexually Transmitted Disease Contagious Disease Other Illness / Injury Hip/Leg/Ankle Injury Knee Injury / Stools Hemorrhoids / Cancer / HIV / Disease / Weakness Numbness / Breath Chronic Cough Pneumothorax Lung Disease / Frequent Indigestion Jaundice Liver Disease / decompression sickness / Surgery Gallbladder Disease / No Herniated Disc / PFO Repair High Blood Pressure Asthma / pain / Viscera Hernia / Disease Staph Infections Tumor / Injury / Wheezing Coughing / No Yes No Yes Convulsions / Other Skin Rash / Thyroid Disease Blood Disease Anemia / Mental Illness/Depression / Balance/Dizziness Severe Motion Sickness Unconsciousness Fainting Spells Wear Contacts/Glasses Color Vision Defect Eye Disease / Diabetes Goiter / Pulmonary Function FVC FEV1 FEV1/FVC / Back Strain / injuries / Bleeding Frequent Indigestion Jaundice Liver Disease / /
MedicalTreatment
Angioplasty / Surgery / /
Person
Toxicity Vertigo / Injury Disabling / Ray Yes / Ray Audiogram / Optic Oculomotor Trochlear Trigeminal Abducens VII VIII / Face / Injury Disabling Headaches Loss / /
Position
Physician Signature Physician / supervisor / Give physician / Name My Personal Physician / physician / No Head / General / Head / /
Association of Diving Contractors International MEDICAL HISTORY FORM Employer Job Title