HSE AMED Diving Medicals

Telephone/Video Call Assessment Questionnaire

Name___________________________      Date of Birth_____________________

Address____________________________________________________________

Contact details Phone ______________________Email ____________________

Type of diving in past year: ___________________________________________

Number of dives in past year: ______________Maximum depth_____________

Days in Saturation: ______________________

Do you currently have any symptoms of COVID-19 (eg new continuous cough or high temperature or loss of, or change in, normal sense of taste or smell, or shortness of breath) and are self-isolating?   Yes    No

Have you previously had symptoms of COVID-19 or tested positive for coronavirus but were asymptomatic, and have you observed the minimum recovery period set out under Step 2 above? Yes  No

Where previously you had symptoms of COVID-19, are you back to your baseline level of exercise tolerance (eg not getting more out of breath or needing longer recovery times)? Yes     No

Are you included in a group that is shielding in relation to COVID-19? Yes    No

Do you understand your legal duty under regulation 13(1) of the Diving at Work Regulations 1997, which requires that you must not dive in a diving project if you know of anything, including any illness or medical condition, which makes you unfit to dive?  Yes     No

Have you had any new problems with your health since your last diving last medical? Yes     No

Are you pregnant or likely to be pregnant (Females only)?  Yes     No

Are you taking any prescribed or other medication?   Yes     No

Do you have any allergies?  Yes     No

Have you ever had or been treated for decompression illness or other diving issues? Yes     No

Have you ever had or do you now have:

Cancer?   Yes     No

Mental health problems (including panic attacks, claustrophobia)?  Yes     No

Drug and/or alcohol misuse in the past three years?  Yes     No

Lung disease (eg COVID 19, chronic obstructive pulmonary disease, asthma)?  Yes     No

Collapsed lung (pneumothorax)? Yes    No

Injury or surgery to the chest, lungs or heart? Yes     No

Disease of the heart and circulation (eg high blood pressure, angina, heart attack, chest pains, palpitations)? Yes     No

Disease of the brain or nervous system (eg epilepsy, stroke, multiple sclerosis, nerve damage)?Yes     No

Blackouts, recurrent fainting, collapsing or dizziness? Yes     No

Motion sickness? Yes     No

Migraine? Yes     No

Head injury with loss of consciousness or surgery to the head? Yes     No

Bone or joint problems or surgery (eg sciatica, spinal surgery)? Yes     No

Ear, nose, throat or sinus problems? Yes     No

Eye problems (eg loss of vision, double vision)? Yes     No

Diabetes or other hormone problems?  Yes     No

Urinary or kidney problems or (males only) prostate problems?  Yes     No

Stomach or intestinal problems or surgery (including stomas)?   Yes     No

Skin disease? Yes     No

Blood or bleeding disorders? Yes     No

Have you any comments on your medical history?

To the best of my knowledge, the information which I have given is correct and I give my consent to this medical assessment, which is for the purpose of determining fitness to dive under the Diving at Work Regulations. I authorize the release of medical information from this assessment to my G.P. if necessary. I understand that confidential information about health and medical history will be confidentially treated, processed and stored in a secure environment by Bryden Medical Limited and will only be accessed and processed by those that have explicit and reasonable need to do so, with due consideration for Data Protection (GDPR 2018).

I understand that under the Diving at Work Regulations 1997, I must NOT dive if I know of anything, including any illness or medical condition, which makes me unfit to dive.

Signed: ____________________________Print Name: _____________________________ Date: ___________________________________     

Please email completed forms and any questions to Dr Helen Bryden at helen@brydenmedical.com         Thank you.