Form – Try Dives Try Dives Date to perform Try Dives(Required) DD slash MM slash YYYY Personal information Name(Required) First Last E-mail address(Required) DNI / NIE / Passport(Required)City(Required)Telephone (add country code)(Required)HeightWeightFoot sizeHow did you hear about us?TripAdvisorInternetWalkingFor a friendSocial networksOthersWant to receive news, updates and offers? We will add you to our mailing list (Required) Yes No Emergency contactName and surname(Required) First Last Telephone (add country code)(Required)Relationship with the contact(Required)Consent(Required) I agree with the privacy policy.(Required) RECREATIONAL DIVING HEALTH STATUS QUESTIONNAIRE Diving requires good physical and mental health. There are some medical conditions that can be dangerous while scuba diving, which are listed below. Those who have or are predisposed to any of these conditions should be evaluated by a physician. This Diver’s Physician Questionnaire provides a basis for determining whether you should seek such an evaluation. If you have any concerns about your diving fitness and they are not represented on this form, consult with your physician before diving. References to “scuba diving” in this form cover both recreational scuba diving and freediving. This form is designed primarily as an initial medical examination for new divers, but is also appropriate for divers receiving continuing education. For your safety and the safety of others who may dive with you, answer all questions honestly. INSTRUCTIONS Complete this questionnaire as a prerequisite for freediving or scuba training. Note to women: If you are pregnant or trying to become pregnant, do not dive. I have had problems with my lungs or breathing, heart or blood.(Required) Yes No Thoracic surgery, cardiac surgery, heart valve surgery, stent placement or pneumothorax (collapsed lung).(Required) Yes No Asthma, wheezing, severe allergies, hay fever or congested airways in the past 12 months that limit my physical activity or exercise.(Required) Yes No A problem or disease involving my heart such as: angina pectoris, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy or stroke, or I am taking medication for any heart condition.(Required) Yes No Recurrent bronchitis and persistent cough in the past 12 months, or have been diagnosed with emphysema.(Required) Yes No I am over 45 years old.(Required) Yes No I currently smoke or inhale nicotine by other means.(Required) Yes No I have a high cholesterol level.(Required) Yes No I have high blood pressure.(Required) Yes No I have had a family member (1st or 2nd degree of consanguinity) who died of sudden death or heart disease or stroke before age 50, or I have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease, or cardiomyopathy(Required) Yes No I find it difficult to engage in moderate exercise (e.g., walking 1.6 km in 12 minutes or swimming 200 meters without rest), or I have been unable to participate in normal physical activity due to fitness or health reasons in the past 12 months.(Required) Yes No I have had problems with my eyes, ears or nostrils or sinuses.(Required) Yes No Sinus surgery in the last 6 months.(Required) Yes No Diseases of the ear or ear surgery, hearing loss or balance disorders.(Required) Yes No Recurrent sinusitis in the last 12 months.(Required) Yes No Ocular surgery in the last 3 months.(Required) Yes No I have had surgery within the last 12 months or have ongoing problems related to a previous surgery.(Required) Yes No I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffered from persistent neurological injury or disease.(Required) Yes No Head injury with loss of consciousness within the last 5 years.(Required) Yes No Persistent neurological injuries or diseases.(Required) Yes No Recurrent migraine headaches in the last 12 months, or I take medication to prevent them.(Required) Yes No Fainting or blackouts (total/partial loss of consciousness) in the last 5 years.(Required) Yes No Epilepsy, seizures or convulsions, or I take medication to prevent them.(Required) Yes No I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks or an addiction to drugs or alcohol.(Required) Yes No Behavioral health, mental or psychological problems requiring medical or psychiatric treatment.(Required) Yes No Major depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder requiring psychiatric medication/treatment.(Required) Yes No I have been diagnosed with a mental health condition or a learning or developmental disorder that requires ongoing care.(Required) Yes No A drug or alcohol addiction requiring treatment within the last 5 years.(Required) Yes No I have had back problems, hernia, ulcers or diabetes.(Required) Yes No Recurrent back problems in the last 6 months that limit my daily activity.(Required) Yes No Back or spine surgery in the last 12 months.(Required) Yes No Diabetes, whether controlled by insulin or diet, or gestational diabetes within the last 12 months.(Required) Yes No An uncorrected hernia that limits my physical abilities.(Required) Yes No Active or untreated ulcers, problematic wounds or ulcer surgery within the last 6 months.(Required) Yes No I have had stomach or intestinal problems, including recent diarrhea.(Required) Yes No I have ostomy surgery and am not medically cleared to swim or participate in physical activity.(Required) Yes No Dehydration requiring medical intervention in the last 7 days.(Required) Yes No Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.(Required) Yes No Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).(Required) Yes No Active or uncontrolled ulcerative colitis or Crohn's disease.(Required) Yes No Bariatric surgery in the last 12 months.(Required) Yes No I am taking prescription drugs (with the exception of contraceptives or antimalarial drugs).(Required) Yes No Participant’s signature If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and accept the participant statement below with the date and your full name. Name and surname(Required) First Date of birth(Required) DD slash MM slash YYYY Today's date(Required) DD slash MM slash YYYY Consent(Required) I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.(Required)*If youanswered YES to questions 3, 5 or 10 above or to any of the questions in boxes A, B, C, D, E, F AND G, read and accept the above statement with the date and your signature, and take the Medical Evaluation Form to your physician for a medical evaluation. Participation in a dive training program requires the evaluation and approval of your physician. Risk and Liability Statement/ Non-Agency Disclosure GENERAL TRAINING Please read this document carefully and fill in the blanks before signing it. Non-Agency Disclosure and Acknowledgment Agreement I understand and agree that PADI Members (“Members”), including DIVE ACADEMY SANTA POLA and/or any individual PADI Instructors and Divemasters associated with the program in which I am participating are authorized to use the various PADI Trademarks and conduct PADI training, however, they are not agents, employees or franchisees of PADI EMEA Ltd., PADI Americas, Inc. or their subsidiaries or affiliated corporations (“PADI”). I further understand that the Members’ business activities are independent, and are not owned or directed by PADI, and that while PADI sets the standards for PADI dive programs, it is not responsible for, nor does it have the right to control the operations of the Members’ business activities and the day-to-day management of PADI programs and the supervision of divers by Members and their associated personnel. Risk and Liability Statement This is a statement by which you, the certified diver, are informed of the risks of freediving and scuba diving. This statement also sets forth the circumstances under which you participate in the diving experience at your own risk. Your signature on this declaration is required as proof that you have received and read it. It is important that you read the contents of this declaration before signing it. If you do not understand any part of it, please discuss it with your instructor. If you are a minor, this form must also be signed by a parent or guardian. Warning Freediving and scuba diving carry inherent risks that may result in serious injury or death. Diving with compressed air involves certain inherent risks: dysbaric, embolic or other hyperbaric injuries that require treatment in a hyperbaric chamber may occur. Training and certification as an open water diver may involve the need to travel to locations far away, either in time or distance or both, from a decompression chamber. Freediving and scuba diving are physically demanding activities as you will experience during this dive program. You have an obligation to report your medical history truthfully and completely to the dive professionals and the facility where this program takes place. Risk AcceptanceConsent(Required) I understand and agree that neither the dive professionals conducting this program, nor the facilities through which this program is conducted, DIVE ACADEMY SANTA POLA, nor PADI EMEA Ltd., nor PADI Americas, Inc., nor their affiliates or subsidiary corporations, nor any of their respective employees, officers, agents or assigns accept any liability for death, injury or other damages/losses suffered by me to the extent resulting from my own conduct or from anything or any situation under my control involving my own negligence.(Required)Consent(Required) In the absence of any negligence or other breach of duty on the part of the dive professionals conducting this program, the facilities through which this program is conducted, DIVE ACADEMY SANTA POLA, PADI EMEA Ltd., PADI Americas, Inc. and all involved parties referenced above, I understand that my participation in this dive program is entirely at my own risk and responsibility.(Required)Material liability(Required) I understand and accept that any loss or breakage of the equipment provided by Dive Academy will be my full responsibility and I will be responsible for the cost of the equipment on site at the end of the activity.(Required)Consent(Required) I ACKNOWLEDGE RECEIPT OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGEMENT AGREEMENT AND STATEMENT OF RISKS AND LIABILITY AND ACKNOWLEDGE THAT I HAVE READ ALL TERMS PRIOR TO SIGNING SUCH STATEMENTS.(Required)Name and surname(Required) First Today's date(Required) DD slash MM slash YYYY Full name of parent/guardian (if applicable) First
