Scuba Diving Trip Health Declaration Form
Personal Information
Full Name
Date of Birth
Nationality
Phone Number
Email
Emergency Contact
Contact Name
Contact Phone
Relationship
Medical History
Asthma or lung disease
Heart disease or high blood pressure
Diabetes
Epilepsy, seizures, or fainting
Ear or sinus surgery/infection
Currently pregnant
Recent surgery or major injury
Taking prescribed medication
Other medical conditions
If yes to any above, please provide details
Diving Information
Certification Agency & Level
Number of Logged Dives
Date of Last Dive
Declaration & Signature
I declare that the information provided is accurate and complete. I acknowledge understanding of the risks associated with scuba diving and agree to participate at my own risk.
Signature
Date