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City Victoria / / Country Australia / / Facility Royal Adelaide Hospital / Operations In hospital / C/Australian College of Occupational Medicine / / IndustryTerm compressed gas / / MedicalCondition hepatitis A / Paralysis / allergies / peptic ulcer / TB / acid reflux Vomiting / bronchospasm / HIV / invalid pension Other illness / Unconsciousness / liver disease Malaria / Recurrent vomiting / Chronic / exertion Bronchitis / unconsciousness Epilepsy Diabetes / Pneumothorax / muscle tone accompanying unconsciousness / diabetes / frequent headaches Migraine Fainting / pulmonary venous drainage / expiratory airway obstruction / injury / chest pain Coughing / chronic disease / pneumonia Pleurisy / AIDS / bullae / Sudden unconsciousness / epilepsy / Frequent chest colds Asthma / dental procedures Deafness / hepatitis / weight Hernia / Syphilis Diabetes Blood disease / air embolism / Heart disease Asthma / Tuberculosis / Asthma / Lung cysts / / MedicalTreatment drainage / relaxation / ear surgery / / Organization Royal Adelaide Hospital / RAN School of Underwater Medicine / Fractures / South Pacific Underwater Medical Society / C/Australian College of Occupational Medicine / Diving Emergency Service / Hyperbaric Medical Unit / Medicare / / Person Initial / / / Position diver / THE EXAMINING PHYSICIAN / Secretary / CANDIDATE / / Product Severe motion sickness Seasickness medication / / ProvinceOrState Victoria / / Technology X-Ray / / SocialTag 
PRE-DIVE MEDICAL FORM FOR PROSPECTIVE ENTRY-LEVEL SCUBA DIVERS THE FIRST THREE PAGES ARE TO BE COMPLETED BY THE CANDIDATE Surname Other Names