Due to the Coronavirus COVID-19 pandemic, our clinic is currently closed for face to face HSE diving medicals.
We may, however be able to carry out the interim telephone video assessments, to allow for a three month certificate extension, for divers with a recently expired one year HSE MA2 certificate.
Telephone 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.
