Please print legibly.
Name ____________________________________________ Birth Date _______ Age _____
First Initial Last
Mailing Address ___________________________________________________________________________
City _________________________________ State/Province ______________
Country __________________________________ Zip/Postal Code ______________
Home Phone (____)__________________ Business Phone (____)________________
Telephone ___________________ FAX ____________________
Name and address of your family care physician
Physician _________________________ Clinic/Hospital _____________________
Address _____________________________________________________________Phone (____)_________
Date of last physical examination ___________________
Name of examiner ____________________________ Clinic/Hospital ________________________
Address _____________________________________________________________Phone (___)_________
Were you ever required to have a physical for diving? _____ Yes _____ No If so, when?______________
This person is an applicant for training or is presently certified to engage in scuba (self contained underwater breathing apparatus) diving. Your opinion of the applicant's medical fitness for scuba diving is requested. Please review Guidelines for Recreational Scuba Diver's Physical
Examination.
Physician's Impression
______ I find no medical conditions that I consider imcompatible with diving.
______ I am unable to recommend this individual for diving.
Remarks ___________________________________________________________________________
I have reviewed Guidelines for Recreational Scuba Diver's Physical Examination.
___________________________________________________ , M.D. Date _________
Physician's Signature
Physician _______________________ Clinic/Hospital _______________________
Address ________________________________________________________________
Phone (____)____________________________________________________________