Below is the full text/questions for the Freediving medical statement.
Important: Please read carefully before filling out. Freediving is a strenuous activity carried out in the underwater environment, which may, under certain conditions, increase your risk of injury. This risk may be significantly increased if you have certain medical conditions. This statement has been developed to make you aware of these conditions. The purpose of a medical statement is to find out, if you should be examined by a doctor before participating in any Freediving activity events. Please read each question carefully and answer them accurately. Please explain any “yes” answer. A positive answer will not necessarily exclude you from participating in any Auckland Freediving Club endorsed events / training competitions. But it will require a medical clearance from a physician. This form and your answers will be kept confidential.
1 NEUROLOGICAL CONDITIONS - Any history of seizure disorder, stroke, brain surgery, black out, severe migraine headaches, or aneurysm of the brain’s blood vessels.
2 CARDIOVASCULAR CONDITIONS - Heart attack, heart surgery, irregular heart beat, uncontrolled elevated blood pressure.
3 PULMONARY CONDITIONS - Any history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breath.
4 EAR CONDITIONS - Permanent holes of the eardrums, history of ruptured eardrum, severely impaired hearing or hearing loss in one or both ears, or ear surgery.
5 SINUS CONDITIONS - Tumor, polyps, cysts of the sinus cavities or nasal passages, sinus surgery, or persistent sinus infections.
6 ASTHMA - History of asthma or asthma attacks, history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any conditions requiring medications and/or use of an inhaler for control of wheezing.
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 or produces episodes of hypoglycaemia (low blood sugar reactions) hyperglycemia (extremely high blood sugar) or if there is related kidney disease, eye disease, heart disease or blood vessel disease. Also, of history of elevated blood sugar during pregnancy.
- PREGNANCY - Are you presently pregnant?
- FREEDIVING / SCUBA DIVING CONDITIONS - Previous history of a diving accident, decompression sickness, decompression of the inner ear or air embolus.
10 MEDICATION - Do you take any medication on a regular basis either over the counter or prescribed by a physician.
11 GENERAL MEDICAL PROBLEMS - Any physical and / or emotional condition not mentioned that might effect your safety in an underwater environment or affect your judgment under times of physical or emotional stress.
12 RECENT ILL HEALTH - You should not participate in apnea activities until fully recovered from ill health.