Last Name

First Name

Reservation Date

Cetification Number

Certification Level

Total Number of Dives

Last Dive's Date

Hotel Name

Room Number

Email Address

Mobile Number

Nationality

Emergency Contact Information (Name / Relationship / Mobile Number):

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. 1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. Yes No

2. I am over 45 years of age. 2. I am over 45 years of age. Yes No

3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to f􀁁ness or health reasons within the past 12 months. 3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to f􀁁ness or health reasons within the past 12 months. Yes No

4. I have had problems with my eyes, ears, or nasal passages/sinuses. 4. I have had problems with my eyes, ears, or nasal passages/sinuses. Yes No

5. I have had surgery within the lost 12 months. OR I have ongoing problems related to past surgery. 5. I have had surgery within the lost 12 months. OR I have ongoing problems related to past surgery. Yes No

6. I have lost consciousness. hod migraine headaches. seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. 6. I have lost consciousness. hod migraine headaches. seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. Yes No

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems. personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I hove been diagnosed with a learning or developmental disability. 7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems. personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I hove been diagnosed with a learning or developmental disability. Yes No

8. I have had back problems. hernia, ulcers, or diabetes. 8. I have had back problems. hernia, ulcers, or diabetes. Yes No

9. I have had stomach or intestine problems, including recent diarrhea. 9. I have had stomach or intestine problems, including recent diarrhea. Yes No

10. I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Loriom). 10. I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Loriom). Yes No

Participant Signature (or, if a minor. participant's parent/guardian signature required. SaveClear

Date

Participant Name

Date of Birth

Instructor Name

Facility Name

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker. neurostimulator), pneumothorax, and/or chronic lung disease. Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker. neurostimulator), pneumothorax, and/or chronic lung disease. Yes No

Asthma. wheezing, severe ollergies, hoy fever or congested airways within the last 12 months that limits my physicol octivity/exercise. Asthma. wheezing, severe ollergies, hoy fever or congested airways within the last 12 months that limits my physicol octivity/exercise. Yes No

A problem or illness involving my heart such as: angina, chest pain on exertion, heart foilure, immersion pulmonary edema, heort attock or stroke, OR am taking medication for any heart condition. A problem or illness involving my heart such as: angina, chest pain on exertion, heart foilure, immersion pulmonary edema, heort attock or stroke, OR am taking medication for any heart condition. Yes No

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. Yes No

Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. Yes No

I currently smoke or inhale nicotine by other means. I currently smoke or inhale nicotine by other means. Yes No

I have a high cholesterol level. I have a high cholesterol level. Yes No

I have high blood pressure. I have high blood pressure. Yes No

I have hod a close blood relative die suddenly or of cordiac disease or stroke before the age of 50, OR hove a family history of heort disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). I have hod a close blood relative die suddenly or of cordiac disease or stroke before the age of 50, OR hove a family history of heort disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). Yes No

Sinus surgery within the last 6 months. Sinus surgery within the last 6 months. Yes No

Ear disease or eor surgery, hearing loss, or problems with balance Ear disease or eor surgery, hearing loss, or problems with balance Yes No

Recurrent sinusitis within the past 12 months. Recurrent sinusitis within the past 12 months. Yes No

Eye surgery within the past 3 months Eye surgery within the past 3 months Yes No

Head injury with loss of consciousness within the post 5 years. Head injury with loss of consciousness within the post 5 years. Yes No

Persistent neurologic injury or disease. Persistent neurologic injury or disease. Yes No

Recurring migraine headaches within the past 12 months. or take medications to prevent them. Recurring migraine headaches within the past 12 months. or take medications to prevent them. Yes No

Blockouts or fainting (full/parti:il loss of consciousness) within the last 5 years. Blockouts or fainting (full/parti:il loss of consciousness) within the last 5 years. Yes No

Epilepsy, seizures, or convulsions. OR take medications to prevent them. Epilepsy, seizures, or convulsions. OR take medications to prevent them. Yes No

Behavioral health, mental or psychologicol problems requiring medical/psychiatric treatment. Behavioral health, mental or psychologicol problems requiring medical/psychiatric treatment. Yes No

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric tre:itment Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric tre:itment Yes No

Been diagnosed with a mental health condition or ::. learning/developmental disorder that requires ongoing care or special accommodation. Been diagnosed with a mental health condition or ::. learning/developmental disorder that requires ongoing care or special accommodation. Yes No

An oddiction to drugs or alcohol requiring treatment within the lost 5 years. An oddiction to drugs or alcohol requiring treatment within the lost 5 years. Yes No

Recurrent back problems in the last 6 months that limit my everydoy activity Recurrent back problems in the last 6 months that limit my everydoy activity Yes No

Back or spinal surgery within the last 12 months. Back or spinal surgery within the last 12 months. Yes No

Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. Yes No

An uncorrected hernia that limits my physical abilities. An uncorrected hernia that limits my physical abilities. Yes No

Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months Yes No

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. Ostomy surgery and do not have medical clearance to swim or engage in physical activity. Yes No

Dehydration requiring medical intervention within the last 7 days. Dehydration requiring medical intervention within the last 7 days. Yes No

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. Yes No

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERO). Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERO). Yes No

Active or uncontrolled ulcerative colitis or Crohn's disease. Active or uncontrolled ulcerative colitis or Crohn's disease. Yes No

Bariatric surgery within the last 12 months. Bariatric surgery within the last 12 months. Yes No

First Name

Last Name

Date

Participant Signature SaveClear

Date

Signature of Parent or Guardian (where applicable) SaveClear

First Name

Last Name

Diving Instructor

Vessel Name

Participant Signature SaveClear

Date

Signature of Parent of Guardian (where applicable) SaveClear

Date