Try Diver Self Certify The completion of this form is a requirement for any person who wishes to experience a try dive. If any given answers are "Yes" then please fill out the text box at the bottom of the form with the relevant details for our Medical Officer to review. If you are uncomfortable with providing personal information please say so in the textbox and we can arrange another means to discussing this. Answering no to every question indicates that you not identified any medical condition that is considered incompatible with recreational diving. Manchester Diving Group reserve the right to refuse a try dive to any applicant at any time and for any reason.Name(Required) First Last Email(Required) How would you rate your own simming ability?(Required) Competitive (can swim 300 yards or greater) Very good (can swim 100 yards or greater) Adequate Low (can swim 10 yards or more) Cannot swim without assistance Have you ever had or suffered from:Diseases or conditions of the heart and circulation including high blood pressure (or taking tablets for high blood pressure), chest pains, angina, heart attack, heart rhythm problems, heart murmur or palpitations?(Required) No Yes Chest or heart surgery?(Required) No Yes Significant bleeding or blood disorders?(Required) No Yes Asthma, chronic obstructive airways disease or ever used an inhaler?(Required) No Yes Collapsed lung, pneumothorax or any other lung injury or problem (except COVID-19)?(Required) No Yes Blackouts, loss of consciousness, any ongoing secondary effects of this, fainting or recurrent dizziness?(Required) No Yes Epilepsy or fits?(Required) No Yes Abdominal surgery, Ileostomy, colostomy or repair of a hiatus hernia?(Required) No Yes Disease of the brain or nervous system (including strokes or multiple sclerosis) orrecurrent migraines?(Required) No Yes Back or spinal surgery or any serious back problems?(Required) No Yes Psychological illness of any kind, fear of small spaces, suicidal thoughts or panic attacks?(Required) No Yes A requirement for Medical Referee assessment in the guidance on Neurodiversity/ASD/ADHD?(Required) No Yes Diabetes?(Required) No Yes Cancer, malignant disease or a tumour?(Required) No Yes Decompression illness, immersion induced pulmonary oedema or other diving related problem?(Required) No Yes Do you currently have a requirement for any prescribed medication (except the contraceptive pill or HRT)?(Required) No Yes Have you had regular ear problems in the past 10 years?(Required) No Yes Have you had a head injury with loss of consciousness in the past 5 years?(Required) No Yes Have you ever been refused a diving medical certificate or life insurance or been offered special terms?(Required) No Yes Are you pregnant or do you think you may be pregnant?(Required) No Yes Are you currently receiving medical care or have you consulted a doctor in the last year other than for mild self limiting illnesses that have completely resolved?(Required) No Yes Do you have a latex allergy?(Required) No Yes Are you concerned about any other medical issue that has not been covered by the questions on this questionnaire?(Required) No Yes Do you have any issues related to vision, e.g. extreme long or short sightedness, limited sight?(Required) No Yes Consent(Required) I confirm that the above answers are correct.If you have answered yes to any of the above questions please give details below:(Required) Δ
