Fillable BSA Medical Form (The Pediatric Clinic Orangeburg)

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BSA Medical Form (The Pediatric Clinic Orangeburg)

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Annual Health and Medical Record
(Valid for 12 calendar months)
Policy on Use of the Annual Health and Medical Record
In order to provide better care for its members and to assist them in better understanding their own physical
capabilities, the Boy Scouts of America recommends that everyone who participates in a Scouting event have
an annual medical evaluation by a certified and licensed health-care provider—a physician (MD or DO), nurse
practitioner, or physician assistant. Providing your medical information on this four-part form will help ensure
you meet the minimum standards for participation in various activities. Note that unit leaders must always
protect the privacy of unit participants by protecting their medical information.
Parts A and B are to be completed at least annually by participants in all Scouting events. This health history,
parental/guardian informed consent and hold harmless/release agreement, and talent release statement is to be
completed by the participant and parents/guardians.
Part C is the physical exam that is required for participants in any event that exceeds 72 consecutive hours,
for all high-adventure base participants, or when the nature of the activity is strenuous and demanding. Service
projects or work weekends may fit this description. Part C is to be completed and signed by a certified and
licensed heath-care provider—physician (MD or DO), nurse practitioner, or physician assistant. It is important
to note that the height/weight limits must be strictly adhered to when the event will take the unit more than
30 minutes away from an emergency vehicle–accessible roadway, or when the program requires it, such as
backpacking trips, high-adventure activities, and conservation projects in remote areas. See the FAQs for when
this does not apply.
Part D is required to be reviewed by all participants of a high-adventure program at one of the national high-
adventure bases and shared with the examining health-care provider before completing Part C.
• Philmont Scout Ranch. Participants and guests for Philmont activities that are conducted with limited
access to the backcountry, including most Philmont Training Center conferences and family programs,
will not require completion of Part C. However, participants should review Part D to understand potential
risks inherent at 6,700 feet in elevation in a dry Southwest environment. Please review specific registration
information for the activity or event.
• Northern Tier National High Adventure Base.
• Florida National High Adventure Sea Base. The PADI medical form is also required if scuba diving
at this base.
Risk Factors
Based on the vast experience of the medical community, the BSA has identified the following risk factors that
may limit your participation in various outdoor adventures.
For more information on medical risk factors, visit Scouting Safely on www.scouting.org.
Prescriptions
The taking of prescription medication is the responsibility of the individual taking the medication and/or that
individual’s parent or guardian. A leader, after obtaining all the necessary information, can agree to accept the
responsibility of making sure a youth takes the necessary medication at the appropriate time, but BSA does not
mandate or necessarily encourage the leader to do so. Also, if state laws are more limiting, they must be followed.
Frequently Asked Questions (FAQs)
• PhilmontScoutRanch:www.philmontscoutranch.orgor575-376-2281
• NorthernTierNationalHighAdventureBase:www.ntier.orgor218-365-4811
• FloridaNationalHighAdventureSeaBase:www.bsaseabase.orgor305-664-5612
• NationalScoutJamboree:www.bsajamboree.org
ForfrequentlyaskedquestionsaboutthisAnnualHealthandMedicalRecord,seeScoutingSafelyonlineat
http://www.scouting.org/scoutsource/HealthandSafety.aspx.InformationabouttheHealthInsurancePortability
andAccountabilityAct(HIPAA)maybefoundathttp://www.hipaa.org.
• Excessive body weight
• Heart disease
• Hypertension (high blood pressure)
• Diabetes
• Seizures
• Lack of appropriate immunizations
• Asthma
• Allergies/anaphylaxis
• Muscular/skeletal injuries
• Psychiatric/psychological and
emotional difficulties
High-adventure base participants:
Expedition/crew No.: __________________________________________________
or staff position: _______________________________________________________
680-001
2011 Printing
Rev. 2/2011
Full name: _________________________________ DOB: ______________ Allergies: __________________ Emergency contact No.: ___________________
Annual BSA Health and Medical Record
Part A
GENERAL INFORMATION
Name ___________________________________________________________________ Date of birth ________________________________ Age _____________ Male Female
Address _________________________________________________________________________________________________________________________ Grade completed (youth only) __________
City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. ________________________________
Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________
Social Security No. (optional; may be required by medical facilities for treatment) _______________________ Religious preference ______________________________
Health/accident insurance company __________________________________________________________ Policy No. ________________________________________________________
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.”
In case of emergency, notify:
Name _________________________________________________________________________________ Relationship _____________________________________________________________
Address _________________________________________________________________________________________________________________________________________________________________
Home phone _________________________________________ Business phone _______________________________ Cell phone ___________________________________________
Alternate contact _________________________________________________________________________ Alternate’s phone ___________________________________________________
HEALTH HISTORY
Are you now, or have you ever been treated for any of the following: Allergies or Reaction to:
Yes No Condition Explain
Medication ____________________________________
Food, Plants, or Insect Bites _________________
_________________________________________________
Immunizations:
The following are recommended by the BSA.
Tetanus immunization is required and must
have been received within the last 10 years. If
had disease, put “D” and the year. If immunized,
check the box and the year received.
Yes No Date
Tetanus ________________________
Pertussis _______________________
Diphtheria ______________________
Measles ________________________
Mumps _________________________
Rubella _________________________
Polio ____________________________
Chicken pox____________________
Hepatitis A _____________________
Hepatitis B _____________________
Influenza _______________________
Other (i.e., HIB) ________________
Exemption to immunizations claimed
(form required).
Asthma Last attack: ____________
Diabetes Last HbA1c: ____________
Hypertension (high blood pressure)
Heart disease (e.g., CHF, CAD, MI)
Stroke/TIA
Lung/respiratory disease
Ear/sinus problems
Muscular/skeletal condition
Menstrual problems (women only)
Psychiatric/psychological and
emotional difficulties
Behavioral disorders (e.g., ADD,
ADHD, Asperger syndrome, autism)
Bleeding disorders
Fainting spells
Thyroid disease
Kidney disease
Sickle cell disease
Seizures Last seizure: ____________
Sleep disorders (e.g., sleep apnea)
Use CPAP: Yes
No
Abdominal/digestive problems
Surgery
Serious injury
Other
MEDICATIONS
List all medications currently used. (If additional space is needed, please photocopy
this part of the health form.) Inhalers and EpiPen information must be included, even
if they are for occasional or emergency use only.
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Administration of the above medications is approved by (if required by your state): ________________________/ _______________________
Parent/guardian signature and/or MD/DO, NP, or PA signature
Be sure to bring medications in sufficient quantities and the original containers. Make sure that they are NOT
expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication.
(For more information about immunizations,
as well as the immunization exemption form,
see Scouting Safely on Scouting.org.)
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High-adventure base participants:
Expedition/crew No.: __________________________________________________
or staff position: _______________________________________________________
680-001
2011 Printing
Rev. 2/2011
Part B
INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT
I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally
demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable
rules and standards of conduct.
In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the
emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider
selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of
medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp
medical staff, camp management, and/or any physician or health care provider involved in providing medical care to the participant.
Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable
Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results,
and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s
parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve
the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might
require special consideration for the safe conducting of Scouting activities.
I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other
organizations associated with the activity from any and all claims or liability arising out of this participation.
Without restrictions.
With special considerations or restrictions (list) ____________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
TALENT RELEASE AGREEMENT
I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/
film/videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby
release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other
organizations associated with the activity from any and all liability from such use and publication.
I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/
film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America,
and I specifically waive any right to any compensation I may have for any of the foregoing.
Yes No
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity
for participation in any event or activity.
If I am participating at
Philmont, Philmont Training Center, Northern Tier, or Florida Sea Base: I have also read and
understand the risk advisories explained in Part D, including height and weight requirements and restrictions, and understand
that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not met.
The participant has permission to engage in all high-adventure activities described, except as specifically noted by me or the
health-care provider.
Participant’s name _______________________________________________________________________________________________________
Participant’s signature __________________________________________________________________ Date ____________________________
Parent/guardian’s signature ______________________________________________________________ Date ____________________________
(if participant is under the age of 18)
Second parent/guardian signature ________________________________________________________ Date ____________________________
(if required; for example, CA)
This Annual Health and Medical Record is valid for 12 calendar months.
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a telephone number.
1. Name _________________________________________________________________ Telephone ______________________________________
2. Name _________________________________________________________________ Telephone ______________________________________
3. Name _________________________________________________________________ Telephone ______________________________________
Adults NOT authorized to take youth to and from events:
1. Name __________________________________________________________________________________________________________________
2. Name __________________________________________________________________________________________________________________
3. Name __________________________________________________________________________________________________________________
Part B Full name: ___________________________________________________________ DOB: __________________
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High-adventure base participants:
Expedition/crew No.: __________________________________________________
or staff position: _______________________________________________________
680-001
2011 Printing
Rev. 2/2011
Part C
TO THE EXAMINING HEALTH-CARE PROVIDER (Certified and licensed physicians [MD, DO], nurse practitioners, and physician’s assistants)
You are being asked to certify that this individual has no contraindication for participation in a Scouting experience. For individuals who will be attending a
high-adventure program at one of the national high-adventure bases, please refer to Part D for additional information.
(Part D was made available to me. ❏ Yes ❏ No)
PHYSICAL EXAMINATION
Height (inches) ____________ Weight (pounds)______________ Maximum weight for height __________ Meets height/weight limits Yes No
Blood pressure _______________________ Pulse __________________ Percent body fat (optional) __________________
If you exceed the maximum weight for height as explained on this page and your planned high-adventure activity will take you more than 30 minutes
away from an emergency vehicle–accessible roadway, you will not be allowed to participate. At the discretion of the medical advisors of the event
and/or camp, participation of an individual exceeding the maximum weight for height may be allowed if the body fat percentage measured by the
health-care provider is determined to be 20 percent or less for a female or 15 percent or less for a male. (Philmont requires a water-displacement
test to be used for this determination.) Please call the event leader and/or camp if you have any questions. Enforcing the height/weight guidelines is
strongly encouraged for all other events.
Normal Abnormal
Explain Any
Abnormalities
Range of Mobility Normal Abnormal
Explain Any
Abnormalities
Eyes Knees (both)
Ears Ankles (both)
Nose Spine
Throat
Lungs
Neurological
Other Yes No
Heart Contacts
Abdomen Dentures
Genitalia Braces
Skin Inguinal hernia
Explain
Emotional
adjustment
Medical equipment
(i.e., CPAP, oxygen)
Tuberculosis (TB) skin test (if required by your state for BSA camp staff)
Negative Positive
Allergies (to what agent, type of reaction, treatment): ____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
Restrictions
(if none, so state) ____________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
EXAMINER’S CERTIFICATION
I certify that I have reviewed the health history and examined this person
and find no contraindications for participation in a Scouting experience.
This participant (with noted restrictions above)
True False
Meets height/weight requirements
Does not have uncontrolled heart disease, asthma, or
hypertension
Has not had an orthopedic injury, musculoskeletal
problems, or orthopedic surgery in the last six months
or possesses a letter of clearance from their orthopedic
surgeon or treating physician
Has no uncontrolled psychiatric disorders
Has had no seizures in the last year
Does not have poorly controlled diabetes
If less than 18 years of age and planning to scuba dive,
does not have diabetes, asthma, or seizures
Provider printed name _______________________________________________________
Address _________________________________________________________________________
City, state, zip __________________________________________________________________
Office phone ___________________________________________________________________
Signature ________________________________________________________________________
Date ______________________________________________________________________________
Height
(inches)
Recommended
Weight (lbs)
Allowable
Exception
Maximum
Acceptance
60 97-138 139-166 166
61 101-143 144-172 172
62 104-148 149-178 178
63 107-152 153-183 183
64 111-157 158-189 189
65 114-162 163-195 195
66 118-167 168-201 201
67 121-172 173-207 207
68 125-178 179-214 214
69 129-185 186-220 220
70 132-188 189-226 226
71 136-194 195-233 233
72 140-199 200-239 239
73 144-205 206-246 246
74 148-210 211-252 252
75 152-216 217-260 260
76 156-222 223-267 267
77 160-228 229-274 274
78 164-234 235-281 281
79 & over 170-240 241-295 295
This table is based on the revised Dietary Guidelines for Americans from the U.S.
Dept. of Agriculture and the Dept. of Health & Human Services.
Part C Full name: ______________________________________________________________ DOB: ________________
DO NOT WRITE IN THIS BOX
REVIEW FOR CAMP OR SPECIAL ACTIVITY
Reviewed by ____________________________________________________________________________________________________ Date _______________________________
Further approval required ❏ Yes ❏ No Reason ________________________________________________________________________________________________________
By ______________________________________________________________________________________________________________ Date _______________________________
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Part D
Participation at any of the BSA’s high-adventure bases can be physically, mentally, and emotionally demanding.
To be better prepared, each participant must complete the following before attending any high-adventure base:
• FillinpartsAandBoftheAnnualHealthandMedicalRecord.
• SharePartDwiththeexamininghealth-careprovider.
• Haveaphysicalexambyacertiedandlicensedhealthcareprovider/physician(MD,DO),nursepractitioner,
orphysicianassistant,andhavepartCcompleted.
• Readthefollowinginformation,whichfocusesonspecicrisksatthehigh-adventurebaseyouwillbeattending.
The Trek Experience.Eachhigh-adventurebaseoffersauniqueexperiencethatisnotrisk-free.Knowledgeablestaff
willinstructallparticipantsinsafetymeasurestobefollowed.Bepreparedtolistentoandcarefullyfollowthesesafety
measuresandtoacceptresponsibilityforthehealthandsafetyofyourselfandothers.
Philmont.Eachparticipantmustbeabletocarrya35-to50-poundpackwhilehiking5to12milesperdayinan
isolatedmountainwildernessrangingfrom6,500to12,500feetinelevation.Summer/autumnclimaticconditions
includetemperaturesfrom30to90degrees,lowhumidity(10to30percent),andfrequent,sometimessevere,
afternoonthunderstorms.Activitiesincludehorsebackriding,rockclimbingandrappelling,challengeevents,pole
climbing,blackpowdershooting,12-gaugetrapshooting,.30-06shooting,trailbuilding,mountainbiking,andother
activitiesthathavepotentialforinjury.
Winterclimaticconditionscanrangefrom-20to60degrees.FortheKanikExperience,eachpersonwillwalk,ski,or
snowshoealongsnow-coveredtrailspullingloadedtoboggansorsledsforupto3miles,ormoreonacross-country
skitrek.RefertothePhilmontScoutRanchwebsiteforspecicinformation.
Northern Tier.Eachpersonmustbeabletocarrya50-to85-poundpackorcanoefromaquarter-mileto2miles
severaltimesadayonrough,swampy,androckyportagesandpaddle10to15milesperday,oftenagainstaheadwind.
Climaticconditionscanrangefrom30to100degreesinsummer/autumnandfrom-40to40degreesinthewinter.
FortheOkpikExperience,eachpersonwillwalk,ski,orsnowshoealongsnow-coveredtrailsoracrossfrozenlakes,
pullingloadedtoboggansorsledsforupto3miles,ormoreifonacross-countryskitrek.RefertotheNorthernTier
websiteforspecicinformation.
Florida Sea Base.ClimaticconditionsatFloridaSeaBaseincludetemperaturesrangingfrom50to95degrees,high
humidity,heatindexreachingto110degrees,andfrequent,sometimessevere,afternoonthunderstorms.Activities
includesnorkeling,scubadiving,kayaking,canoeing,sailing,hiking,andotheractivitiesthathavepotentialforinjury.
RefertotheSeaBasewebsiteforspecicinformation.
Risk Advisory.Allofthehigh-adventurebaseshaveexcellenthealthandsafetyrecordsandstrivetominimizerisks
toparticipantsandadvisorsbyemphasizingappropriatesafetyprecautions.Becausemostparticipantsareprepared,
areconsciousofrisks,andtakesafetyprecautions,theydonotexperienceinjuries.IfyoudecidetoattendPhilmont,
NorthernTier,orFloridaSeaBase,youshouldbephysicallyt,haveproperclothingandequipment,andbewillingto
followinstructions,workasateamwithyourcrew,andtakeresponsibilityforyourownhealthandsafety.
Parents,guardians,andparticipantsinanyhigh-adventureprogramareadvisedthatjourneyingtoandfromthesebases
caninvolveexposuretoaccidents,illness,and/orinjury.
High-adventurestaffmembershavebeentrainedinrstaid,CPR,andaccidentpreventionandarepreparedtoassistthe
adultadvisorinrecognizing,reactingto,andrespondingtoaccidents,injuries,andillnessesasneeded.Eachcrewisrequired
tohaveatleastonemembertrainedinwildernessrstaidandCPR.Medicalandsearch-and-rescueservicesareprovidedin
responsetoanaccidentoremergency.However, response times can be affected by location, terrain, weather, or other
emergencies and could be delayed for hours or even days in a wilderness setting.
Philmont. ParticipantsandguestsforPhilmontactivitiesthatareconductedwithlimitedaccesstothebackcountry,
includingmostPhilmontTrainingCenterconferencesandfamilyprograms,shouldreviewPartDtounderstand
potentialhealthrisksinherentat6,700feetinelevationinadrySouthwestenvironment.
Highelevation;physicallydemandinghigh-adventureprograminremotemountainousareas;campingwhilebeing
exposedtooccasionalsevereweatherconditionssuchaslightning,hail,ashoods,andheat;andotherpotential
problems,includinginjuriesfromtrippingandfalling,fallsfromhorses,heatexhaustion,andmotorvehicleaccidents,
canworsenunderlyingmedicalconditions.Philmont’strailsaresteepandrocky.Wildanimalssuchasbears,
rattlesnakes,andmountainlionsarenativeandusuallypresentlittledangerifproperprecautionsaretaken.Please
callPhilmont(575-376-2281)ifyouhaveanyquestions.
Northern Tier. WhileparticipatinginNorthernTier’scanoeingandcampingwildernessareas,lifejacketsmustbe
wornatalltimeswhenonthewater.Crewmemberstraveltogetheratalltimes.Emergencycommunicationsvia
radio,andinmoreremotelocationsbysatellitephone,areprovidedbyNorthernTier.Radiocommunicationand/
oremergencyevacuationcanbehamperedbyweather,terrain,distance,equipmentmalfunction,andotherfactors,
andarenotasubstitutefortakingappropriateprecautionsandhavingadequaterst-aidknowledgeandequipment.
PleasecallNorthernTier(218-365-4811)ifyouhaveanyquestions.
Florida Sea Base.Severalactivitiesareoffered,includingsnorkeling,sailing,camping,kayaking,canoeing,swimming,
shing,andscubadiving.Divingisanexcitinganddemandingactivity.Whenperformedcorrectly,itisverysafe.
Whenestablishedsafetyproceduresarenotfollowed,however,thereareextremedangers.Allparticipantswillneedto
learnfromtheinstructortheimportantsafetyrulesregardingbreathingandequalizationwhilescubadiving.Improper
useofscubaequipmentcanresultinseriousinjury,soparticipantsmustbeinstructedtousetheequipmentsafely
underdirectsupervisionofaqualiedinstructor.
To scuba dive safely, participants must not be extremely overweight or in poor physical condition. Diving can be
strenuous under certain conditions. Participants’ respiratory and circulatory systems must be in good health. All body
air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma,
or a severe medical problem, or who is under the influence of alcohol or drugs, should not dive. If taking medication,
participants should consult a doctor and the instructor before participation in this program. If there is a question about
theadvisabilityofparticipation,contactthefamilyphysicianrst,thencalltheSeaBaseat305-664-4173.TheSeaBase
health supervisor reserves the right to make medical decisions regarding the participation of individual at Sea Base.
Food. Each base offers food appropriate for the experience. If a participant has a problem with the diet described in the
participant guide, please contact the high-adventure base you are considering attending.
Medications. Each participant who has a condition requiring medication should bring an appropriate supply for the
duration of the trip. Consider bringing duplicate or even triplicate supplies of vital medications. People with allergies that
have resulted in severe reactions or anaphylaxis must bring with them an EpiPen that has not expired.
Immunizations.Eachparticipantmusthavereceivedatetanusimmunizationwithinthelast10years.Recognitionwill
be given to the rights of those Scouts and Scouters who do not have immunizations because of philosophical, political,
or religious beliefs. In such a situation, the Immunization Exemption Request form is required.
Recommendations Regarding Chronic Illnesses. Each base requires that this information be shared with the
parents or guardians and examining physician of every participant. There are no facilities for extended care or treatment;
therefore participants who cannot meet these requirements will be sent home at their expense.
Staff and/or staff physicians reserve the right to deny the participation of any individual on the basis of a
physical examination and/or medical history.
Adults or youth who have had any of the following conditions should undergo a thorough evaluation by a
physician before considering participation at a BSA high-adventure base.
Cardiac or Cardiovascular Disease, including:
1.Angina(chestpaincausedbyblockedbloodvesselsorcomingfromtheheart)
2. Myocardial infarction (heart attack)
3. Heart surgery or heart catheterization (including angioplasty to treat blocked blood vessels, balloon dilation, or stents)
4.Strokeortransientischemicattacks(TIAs)
5.Claudication(legpainwithexercise,causedbyhardeningofthearteries)
6.Familyhistoryofheartdiseaseorafamilymemberwhodiedunexpectedlybeforeage50
7. Diabetes
8.Smoking
9. Excessive weight
Youthwhohaveacongenitalheartdiseaseoranacquiredheartdiseasesuchasrheumaticfever,Kawasaki’sdisease,
or mitral valve prolapse should undergo thorough evaluation by a physician before considering participating at a high-
adenture base. The physical exertion at any of the high-adventure bases may precipitate either a heart attack or stroke in
susceptible persons. Participants with a history of any of the first seven conditions listed above should have a physician-
supervised stress test. More extensive testing (e.g., nuclear stress test) is recommended for participants who have
coronary heart disease. Even if the stress test results are normal, the results of testing done at lower elevations,
without backpacks, do not guarantee safety. If the test results are abnormal, the individual is advised
not to participate.
Hypertension (High Blood Pressure). The combination of physical, mental, and emotional stress, increased exertion
and/or heat, and altitude appears to cause a significant increase in blood pressure in some individuals. Occasionally,
hypertension reaches such a level that it is no longer safe to engage in strenuous activity. Hypertension can increase the
risk of having a stroke, heart attack, or angina. Participants should have a normal blood pressure (less than 140/90).
Personswithsignicanthypertension(greaterthan140/90)shouldbetreatedandcontrolledbeforeattendinganyhigh-
adventure base, and should continue on medications while participating. The goal of treatment should be to lower the
blood pressure to normal. Participants already on antihypertensive therapy with normal blood pressure should continue
on medications. Individuals taking diuretics to treat hypertension are at increased risk for dehydration related to strenuous
physical activity and should be careful to maintain good hydration during the trek.
Philmont. Eachparticipantwhois18yearsofageorolderwillhavehisorherbloodpressurecheckedatPhilmont.Those
individuals with a blood pressure consistently greater than 160/100 at Philmont may be kept off the trail until their
blood pressure decreases.
Florida Sea Base. Those taking beta-blocker medication should consider a change of medication before participating in any
scuba program.
Insulin-Dependent Diabetes Mellitus. Exercise and the type of food eaten affect insulin requirements. Any individual
with insulin-dependent diabetes mellitus should be able to monitor personal blood glucose and to know how to adjust
insulin doses based on these factors. The person with diabetes also should know how to give a self-injection. Both the
person with diabetes and one other person in the group should be able to recognize indications of excessively high
blood sugar (hyperglycemia or diabetic ketoacidosis) and excessively low blood sugar (hypoglycemia). The person with
diabetes and one other individual should know the appropriate initial responses for these conditions. An insulin-dependent
person who has been newly diagnosed (within the last six months) or who has undergone a change in delivery system
(e.g., insulin pump) in the last six months should not attempt to participate. A person with diabetes who has had frequent
hospitalizations for diabetic ketoacidosis or who has had frequent problems with hypoglycemia should not participate until
better control of the diabetes has been achieved.
Philmont. It is recommended that the person with diabetes and one other individual carry insulin on the trek (in case
of accident) and that a third vial be kept at the Health Lodge for backup. Bring insulin in a small insulated container.
Bring enough testing equipment and supplies for the entire trip and trek. Extras are usually needed. If an individual
has been hospitalized for diabetes-related illnesses within the past year, the individual must obtain permission to
participatebycontactingthePhilmontHealthLodgeat575-376-2281.
Florida Sea Base.Personswithdiabeteswhoare18yearsofageorolderwhowishtoscubadiveshouldbeassessed
by a physician familiar with both hyperbaric issues related to diabetes and medications used for the control and treatment
ofdiabetes.Persons18yearsoldorolderwhoaredeterminedtobecandidatesforscubadivingmustsubmitfour
hemoglobinA1c(HbA1c)tests,eachwithHbA1cvalueslessthan7,takenwithintheprevious12months.Anytestwithin
thepast12monthswithanHbA1cvaluegreaterthan7disqualiesapersonfromscubadivingaspartofaBSAactivity.
Personslessthan18yearsofagewithType1diabeteswillnotbeallowedtoscubadive.Personsundertheageof18
who control their diabetes with exercise and diet (no medications) and can provide three sequential hemoglobin tests
withHbA1cvalueslessthan6maybeapprovedtoscubadive.
Seizures (Epilepsy). A seizure disorder or epilepsy does not exclude an individual from participating at a high-adventure
base. However, the seizure disorder should be well-controlled by medications. A minimum one year seizure-free period
is considered to be adequate control. Exceptions to this guideline may be considered on an individual basis, and will be
based on the specific type of seizure and the likely risks to the individual and to other members of the crew.
Florida Sea Base. Any seizure activity within the past five years, regardless of control and/or medication, disqualifies
an individual from participation in any scuba program. A person with a history of seizure activity who has been
asymptomatic AND medication-free for five years, as evidenced by a physician, will be allowed to dive.
Asthma. Asthma should be well-controlled before participating at any high-adventure base. Well-controlled asthma
means:1)theuseofarescueinhaler(e.g.,albuterol)lessthanoncedaily;2)noneedfornighttimetreatmentwitha
rescue inhaler (e.g., albuterol). Well-controlled asthma may include the use of long-acting bronchodilators, inhaled
steroids,ororalmedicationssuchasSingulair.Youmustmeettheseguidelinesinordertoparticipate.Youwillnotbe
allowedtoparticipateif:1)youhaveexerciseasthmanotpreventedbymedications;or2)youhavebeenhospitalized
or have gone to the emergency room to treat asthma in the past six months; or 3) you have needed treatment with
intravenous, intramuscular, or oral steroids (prednisone) in the past six months. You must bring an ample supply of your
medications and a spare rescue inhaler that are not expired. At least one other member of the crew should know how to
recognize signs of worsening asthma or an asthma attack, and should know how to use the rescue inhaler. Any person
who has needed treatment for asthma in the past three years must carry a rescue inhaler on the trek. If you do
not bring a rescue inhaler, you must buy one before you will be allowed to participate.
Florida Sea Base. Persons being treated for asthma (including reactive airway disease) are disqualified from BSA scuba
programs. Persons with a history of asthma who have been asymptomatic and have not used medications to control
asthma for five years or more may be allowed to scuba dive as part of a BSA activity upon submission of evidence from
their treating physician. Persons with a history of asthma who have been asymptomatic and have not used medication
to control asthma for less than five years may be allowed to scuba dive as part of a BSA activity upon submission of
a methacholine challenge test showing the asthma to be resolved.
Allergy or Anaphylaxis. Persons who have had an anaphylactic reaction from any cause must contact the high-
adventure base before arrival. If you are allowed to participate, you will be required to have appropriate treatment with you.
Youandatleastoneothermemberofyourcrewmustknowhowtogivethetreatment.Ifyoudonotbringappropriate
treatment with you, you will be required to buy it before you will be allowed to participate.
Recent Musculoskeletal Injuries and Orthopedic Surgery. Every participant will put a great deal of strain on feet,
ankles, and knees due to negotiating steep, rocky trails with a backpack; paddling and portaging heavy gear over irregular
terrain; or climbing into and out of a boat. Therefore, individuals with significant musculoskeletal problems (including back
problems) or orthopedic surgery/injuries within the last 6 months must have a letter of clearance from their orthopedic
surgeon or treating physician to be considered for approval to participate. Permission is not guaranteed. A person with
a cast on any extremity may participate only if approved by the high-adventure base. Ingrown toenails are a common
problem and must be treated 30 days prior to arrival.
Psychological and Emotional Difficulties. A psychological disorder does not necessarily exclude an individual from
participation. Parents and advisers should be aware that no high-adventure experience is designed to assist participants
in overcoming psychological or emotional problems. Experience demonstrates that these problems frequently become
magnified, not lessened, when a participant is subjected to the physical and mental challenges of a remote wilderness setting.
Any condition should be well-controlled without the services of a mental health practitioner. Under no circumstance
should medication be stopped immediately prior to participation, and medication should be continued throughout
the entire high-adventure experience. Participants requiring medication must bring an appropriate supply for the
duration of the trip.
680-001
2011 Printing
Rev. 2/2011
Weight Limits. Weight limit guidelines are used because overweight individuals are at a greater risk for heart disease,
high blood pressure, stroke, altitude illness, sleep problems, and injury. Those who fall within the limits are more likely to
have an enjoyable trek and avoid incurring health risks.
Philmont. Each participant in a Philmont trek must not exceed the maximum acceptable limit in the weight chart shown
below. The right-hand column shows the maximum acceptable weight for a person’s height in order to participate in a
Philmont trek.
Participants 21 years and older who exceed the maximum acceptable weight limit for their height at the
Philmont medical recheck WILL NOT be permitted to backpack or hike at Philmont. They will be sent home.
For example, a person 70 inches tall cannot weigh more than 226 pounds. All heights and weights will be measured
in stocking feet.
For participants under 21 years of age who exceed the maximum acceptable weight for height, the Philmont
physicians will use their best professional judgment in determining participation in a Philmont trek. Philmont will
consider up to 20 pounds over the maximum acceptable as stated on the chart; however exceptions are not made
automatically, and discussion in advance with Philmont is required regarding any exception to the weight limit
for persons under 21 years of age. Philmont’s telephone number is 575-376-2281.
Under no circumstances will any individual weighing more than 295 pounds be permitted to participate in
backcountry programs. This requirement is necessary due to rescue equipment restrictions and for the safety of
search-and-rescue personnel.
The maximum weight for any participant in a Cavalcade Trek and for horse rides is 200 pounds.
Participants and guests in Philmont activities, including most Philmont Training Center conference and family
programs, who will participate in limited backcountry access during their visit must not exceed the maximum
acceptable limit in the weight chart.
Northern Tier. Each participant in a Northern Tier expedition should not exceed the maximum acceptable weight for
height in the table shown on the Annual Health and Medical Record form. Those who fall within the recommended
weight limits are much more likely to have an enjoyable trek and avoid incurring injuries and health risks. Extra weight
puts strain on the back, joints, and feet. The portage trails can be very muddy, slippery, and rocky, and present a
potential for tripping and falling. We also strongly recommend that no participant be less than 100 pounds in weight.
Extremely small participants will have a very difficult time carrying canoes and heavy packs.
Canoes’ loads are another important reason to limit participant weight. Northern Tier assigns three people to a canoe.
The total participant load per canoe must not exceed 600 pounds, or an average of 200 pounds per participant.
Northern Tier does not permit individuals exceeding 295 pounds to participate in high-adventure programs.
Florida Sea Base. Any participant or advisor who exceeds the maximum weight limits on the weight chart may want
to reconsider participation in a Sea Base high-adventure program. Anyone who exceeds these limits is at extreme risk
for health problems. Participants who fall within the guidelines are more likely to have an enjoyable program and avoid
incurring health risks. The absolute weight limit for our programs is 295 pounds.
Height
(inches)
Recommended
Weight (lbs)
Allowable
Exception
Maximum
Acceptance
60 97-138 139-166 166
61 101-143 144-172 172
62 104-148 149-178 178
63 107-152 153-183 183
64 111-157 158-189 189
65 114-162 163-195 195
66 118-167 168-201 201
67 121-172 173-207 207
68 125-178 179-214 214
69 129-185 186-220 220
Height
(inches)
Recommended
Weight (lbs)
Allowable
Exception
Maximum
Acceptance
70 132-188 189-226 226
71 136-194 195-233 233
72 140-199 200-239 239
73 144-205 206-246 246
74 148-210 211-252 252
75 152-216 217-260 260
76 156-222 223-267 267
77 160-228 229-274 274
78 164-234 235-281 281
79 & over 170-240 241-295 295
This table is based on the revised Dietary Guidelines for Americans from the U.S. Dept. of Agriculture and the Dept. of Health & Human Services.
MEDICAL STATEMENT
Participant Record (Confidential Information)
This is a statement in which you are informed of some potential risks
involved in scuba diving and of the conduct required of you during the
scuba training program. Your signature on this statement is required for
you to participate in the scuba training program offered
by_____________________________________________________and
Instructor
_______________________________________________located in the
Facility
city of_______________________, state/province of _______________.
Read this statement prior to signing it. You must complete this
Medical Statement, which includes the medical questionnaire section, to
enroll in the scuba training program. If you are a minor, you must have
this Statement signed by a parent or guardian.
Diving is an exciting and demanding activity. When performed
correctly, applying correct techniques, it is relatively safe. When
established safety procedures are not followed, however, there are
increased risks.
To scuba dive safely, you should not be extremely overweight or
out of condition. Diving can be strenuous under certain conditions. Your
respiratory and circulatory systems must be in good health. All body air
spaces must be normal and healthy. A person with coronary disease, a
current cold or congestion, epilepsy, a severe medical problem or who is
under the influence of alcohol or drugs should not dive. If you have
asthma, heart disease, other chronic medical conditions or you are tak-
ing medications on a regular basis, you should consult your doctor and
the instructor before participating in this program, and on a regular basis
thereafter upon completion. You will also learn from the instructor the
important safety rules regarding breathing and equalization while scuba
diving. Improper use of scuba equipment can result in serious injury.
You must be thoroughly instructed in its use under direct supervision of
a qualified instructor to use it safely.
If you have any additional questions regarding this Medical
Statement or the Medical Questionnaire section, review them with your
instructor before signing.
Please read carefully before signing.
The purpose of this Medical Questionnaire is to find out if you should be exam-
ined by your doctor before participating in recreational diver training. A positive
response to a question does not necessarily disqualify you from diving. A positive
response means that there is a preexisting condition that may affect your safety
while diving and you must seek the advice of your physician prior to engaging in
dive activities.
Please answer the following questions on your past or present medical history
with a
YES
or
NO
. If you are not sure, answer
YES
. If any of these items apply
to you, we must request that you consult with a physician prior to participating in
scuba diving. Your instructor will supply you with an RSTC Medical Statement
and Guidelines for Recreational Scuba Diver’s Physical Examination to take to
your physician.
_____ Could you be pregnant, or are you attempting to become pregnant?
_____ Are you presently taking prescription medications? (with the exception of
birth control or anti-malarial)
_____ Are you over 45 years of age and can answer YES to one or more of the
following?
• currently smoke a pipe, cigars or cigarettes
• have a high cholesterol level
• have a family history of heart attack or stroke
• are currently receiving medical care
• high blood pressure
• diabetes mellitus, even if controlled by diet alone
Have you ever had or do you currently have…
_____ Asthma, or wheezing with breathing, or wheezing with exercise?
_____ Frequent or severe attacks of hayfever or allergy?
_____ Frequent colds, sinusitis or bronchitis?
_____ Any form of lung disease?
_____ Pneumothorax (collapsed lung)?
_____ Other chest disease or chest surgery?
_____ Behavioral health, mental or psychological problems (Panic attack, fear of
closed or open spaces)?
_____ Epilepsy, seizures, convulsions or take medications to prevent them?
_____ Recurring complicated migraine headaches or take medications to pre-
vent them?
_____ Blackouts or fainting (full/partial loss of consciousness)?
_____ Frequent or severe suffering from motion sickness (seasick, carsick,
etc.)?
_____ Dysentery or dehydration requiring medical intervention?
_____ Any dive accidents or decompression sickness?
_____ Inability to perform moderate exercise (example: walk 1.6 km/one mile
within 12 mins.)?
_____ Head injury with loss of consciousness in the past five years?
_____ Recurrent back problems?
_____ Back or spinal surgery?
_____ Diabetes?
_____ Back, arm or leg problems following surgery, injury or fracture?
_____ High blood pressure or take medicine to control blood pressure?
_____ Heart disease?
_____ Heart attack?
_____ Angina, heart surgery or blood vessel surgery?
_____ Sinus surgery?
_____ Ear disease or surgery, hearing loss or problems with balance?
_____ Recurrent ear problems?
_____ Bleeding or other blood disorders?
_____ Hernia?
_____ Ulcers or ulcer surgery ?
_____ A colostomy or ileostomy?
_____ Recreational drug use or treatment for, or alcoholism in the past five
years?
Divers Medical Questionnaire
To the Participant:
The information I have provided about my medical history is accurate to the best of my knowledge.
I agree to accept
responsibility for omissions regarding my failure to disclose any existing or past health condition.
_______________________________________ _________________ _______________________________________ _________________
Signature Date Signature of Parent or Guardian Date
PRODUCT NO. 10063 (Rev. 9/01) Ver. 2.0
© International PADI, Inc. 1989, 1990, 1998, 2001
© Recreational Scuba Training Council, Inc. 1989, 1990, 1998, 2001
Page 1 of 6
click to sign
signature
click to edit
click to sign
signature
click to edit
STUDENT
Please print legibly.
Name__________________________________________________________________________ Birth Date ________________ Age ________
First Initial Last Day/Month/Year
Mailing Address __________________________________________________________________________________________________________
City________________________________________________________________ State/Province/Region ________________________________
Country ____________________________________________________________ Zip/Postal Code _____________________________________
Home Phone ( )________________________________________ Business Phone ( )______________________________________
Email _____________________________________________________ FAX_______________________________________________________
Name and address of your family physician
Physician __________________________________________________ Clinic/Hospital ______________________________________________
Address________________________________________________________________________________________________________________
Date of last physical examination ________________
Name of examiner____________________________________________ Clinic/Hospital_______________________________________________
Address ________________________________________________________________________________________________________________
Phone ( )___________________________________ Email ________________________________________________________________
Were you ever required to have a physical for diving? Yes No If so, when?________________________________________________
PHYSICIAN
This person applying 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. There are guidelines attached for your information and reference.
Physician’s Impression
I find no medical conditions that I consider incompatible with diving.
I am unable to recommend this individual for diving.
Remarks
___________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________ Date ___________________________
Physician’s Signature or Legal Representative of Medical Practitioner Day/Month/Year
Physician_____________________________________________ Clinic/Hospital_________________________________________
Address____________________________________________________________________________________________________
Phone ( )___________________________________ Email ________________________________________________________________
Page 2 of 6
Recreational
SCUBA
(Self-Contained Underwater Breathing
Apparatus) can provide recreational divers with an enjoyable
sport safer than many other activities. The risk of diving is
increased by certain physical conditions, which the relationship to
diving may not be readily obvious. Thus, it is important to screen
divers for such conditions.
The
RECREATIONAL SCUBA DIVER’S PHYSICAL EXAMINA-
TION
focuses on conditions that may put a diver at increased risk
for decompression sickness, pulmonary overinflation syndrome
with subsequent arterial gas embolization and other conditions
such as loss of consciousness, which could lead to drowning.
Additionally, the diver must be able to withstand some degree of
cold stress, the physiological effects of immersion and the optical
effects of water and have sufficient physical and mental reserves
to deal with possible emergencies.
The history, review of systems and physical examination should
include as a minimum the points listed below. The list of condi-
tions that might adversely affect the diver is not all-inclusive, but
contains the most commonly encountered medical problems. The
brief introductions should serve as an alert to the nature of the
risk posed by each medical problem.
The potential diver and his or her physician must weigh the
pleasures to be had by diving against an increased risk of death
or injury due to the individual’s medical condition. As with any
recreational activity, there are no data for diving enabling the cal-
culation of an accurate mathematical probability of injury. Experi-
ence and physiological principles only permit a qualitative
assessment of relative risk.
For the purposes of this document,
Severe Risk
implies that an
individual is believed to be at substantially elevated risk of decom-
pression sickness, pulmonary or otic barotrauma or altered con-
sciousness with subsequent drowning, compared with the gener-
al population. The consultants involved in drafting this document
would generally discourage a student with such medical prob-
lems from diving.
Relative Risk
refers to a moderate increase in
risk, which in some instances may be acceptable. To make a
decision as to whether diving is contraindicated for this category
of medical problems, physicians must base their judgement on
an assessment of the individual patient. Some medical problems
which may preclude diving are
temporary
in nature or respon-
sive to treatment, allowing the student to dive safely after they
have resolved.
Diagnostic studies and specialty consultations should be obtained
as indicated to determine the diver’s status. A list of references is
included to aid in clarifying issues that arise. Physicians and
other medical professionals of the Divers Alert Network (DAN)
associated with Duke University Health System are available for
consultation by phone +1 919 684 2948 during normal business
hours. For emergency calls, 24 hours 7 days a week, call +1 919
684 8111 or +1 919 684 4DAN (collect). Related organizations
exist in other parts of the world – DAN Europe in Italy +39 039
605 7858, DAN S.E.A.P. in Australia +61 3 9886 9166 and Divers
Emergency Service (DES) in Australia +61 8 8212 9242, DAN
Japan +81 33590 6501 and DAN Southern Africa +27 11 242
0380. There are also a number of informative websites offering
similar advice.
NEUROLOGICAL
Neurological abnormalities affecting a diver’s ability to perform
exercise should be assessed according to the degree of compro-
mise. Some diving physicians feel that conditions in which there
can be a waxing and waning of neurological symptoms and
signs, such as migraine or demyelinating disease, contraindicate
diving because an exacerbation or attack of the preexisting dis-
ease (e.g.: a migraine with aura) may be difficult to distinguish
from neurological decompression sickness. A history of head
injury resulting in unconsciousness should be evaluated for risk
of seizure.
Relative Risk Conditions
• Complicated Migraine Headaches whose symptoms or
severity impair motor or cognitive function, neurologic
manifestations
• History of Head Injury with sequelae other than seizure
• Herniated Nucleus Pulposus
• Intracranial Tumor or Aneurysm
• Peripheral Neuropathy
• Multiple Sclerosis
• Trigeminal Neuralgia
• History of spinal cord or brain injury
Temporary Risk Condition
History of cerebral gas embolism without residual where pul-
monary air trapping has been excluded and for which there
is a satisfactory explanation and some reason to believe that
the probability of recurrence is low.
Severe Risk Conditions
Any abnormalities where there is a significant probability of
unconsciousness, hence putting the diver at increased risk of
drowning. Divers with spinal cord or brain abnormalities where
perfusion is impaired may be at increased risk of decompression
sickness.
Some conditions are as follows:
• History of seizures other than childhood febrile seizures
• History of Transient Ischemic Attack (TIA) or Cerebrovas-
cular Accident (CVA)
• History of Serious (Central Nervous System, Cerebral or
Inner Ear) Decompression Sickness with residual deficits
CARDIOVASCULAR SYSTEMS
Relative Risk Conditions
The diagnoses listed below potentially render the diver unable to
meet the exertional performance requirements likely to be
encountered in recreational diving. These conditions may lead
the diver to experience cardiac ischemia and its consequences.
Formalized stress testing is encouraged if there is any doubt
regarding physical performance capability. The suggested mini-
mum criteria for stress testing in such cases is at least 13
METS.* Failure to meet the exercise criteria would be of signifi-
cant concern. Conditioning and retesting may make later qualifi-
cation possible. Immersion in water causes a redistribution of
blood from the periphery into the central compartment, an effect
that is greatest in cold water. The marked increase in cardiac
preload during immersion can precipitate pulmonary edema in
patients with impaired left ventricular function or significant valvu-
lar disease. The effects of immersion can mostly be gauged by
an assessment of the diver’s performance while swimming on the
surface. A large proportion of scuba diving deaths in North Amer-
ica are due to coronary artery disease. Before being approved to
scuba dive, individuals older than 40 years are recommended to
undergo risk assessment for coronary artery disease. Formal
exercise testing may be needed to assess the risk.
* METS is a term used to describe the metabolic cost. The MET at rest
is one, two METS is two times the resting level, three METS is three
times the resting level, and so on. The resting energy cost (net oxygen
requirement) is thus standardized. (Exercise Physiology; Clark, Prentice
Hall, 1975.)
Guidelines for Recreational Scuba Diver’s Physical Examination
Instructions to the Physician:
Page 3 of 6
Relative Risk Conditions
• History of Coronary Artery Bypass Grafting (CABG)
• Percutaneous Balloon Angioplasty (PCTA) or Coronary
Artery Disease (CAD)
• History of Myocardial Infarction
• Congestive Heart Failure
• Hypertension
• History of dysrythmias requiring medication for suppres-
sion
• Valvular Regurgitation
Pacemakers
The pathologic process that necessitated should be
addressed regarding the diver’s fitness to dive. In those
instances where the problem necessitating pacing does not
preclude diving, will the diver be able to meet the perform-
ance criteria?
* NOTE: Pacemakers must be certified by the manufacturer as able
to withstand the pressure changes involved in recreational diving.
Severe Risks
Venous emboli, commonly produced during decompression,
may cross major intracardiac right-to-left shunts and enter
the cerebral or spinal cord circulations causing neurological
decompression illness. Hypertrophic cardiomyopathy and
valvular stenosis may lead to the sudden onset of uncon-
sciousness during exercise.
PULMONARY
Any process or lesion that impedes airflow from the lungs places
the diver at risk for pulmonary overinflation with alveolar rupture
and the possibility of cerebral air embolization. Many interstitial
diseases predispose to spontaneous pneumothorax: Asthma
(reactive airway disease), Chronic Obstructive Pulmonary Dis-
ease (COPD), cystic or cavitating lung diseases may all cause air
trapping. The 1996 Undersea and Hyperbaric Medical Society
(UHMS) consensus on diving and asthma indicates that for the
risk of pulmonary barotrauma and decompression illness to be
acceptably low, the asthmatic diver should be asymptomatic and
have normal spirometry before and after an exercise test.
Inhalation challenge tests (e.g.: using histamine, hypertonic
saline or methacholine) are not sufficiently standardized to be
interpreted in the context of scuba diving.
A pneumothorax that occurs or reoccurs while diving may be cat-
astrophic. As the diver ascends, air trapped in the cavity
expands and could produce a tension pneumothorax.
In addition to the risk of pulmonary barotrauma, respiratory dis-
ease due to either structural disorders of the lung or chest wall or
neuromuscular disease may impair exercise performance. Struc-
tural disorders of the chest or abdominal wall (e.g.: prune belly),
or neuromuscular disorders, may impair cough, which could be
life threatening if water is aspirated. Respiratory limitation due to
disease is compounded by the combined effects of immersion
(causing a restrictive deficit) and the increase in gas density,
which increases in proportion to the ambient pressure (causing
increased airway resistance). Formal exercise testing may be
helpful.
Relative Risk Conditions
• History of Asthma or Reactive Airway Disease (RAD)*
• History of Exercise Induced Bronchospasm (EIB)*
• History of solid, cystic or cavitating lesion*
• Pneumothorax secondary to:
-Thoracic Surgery
-Trauma or Pleural Penetration*
-Previous Overinflation Injury*
• Obesity
• History of Immersion Pulmonary Edema Restrictive Dis-
ease*
• Interstitial lung disease: May increase the risk of pneu-
mothorax
* Spirometry should be normal before and after exercise
Active Reactive Airway Disease, Active Asthma, Exercise
Induced Bronchospasm, Chronic Obstructive Pulmonary
Disease or history of same with abnormal PFTs or a positive
exercise challenge are concerns for diving.
Severe Risk Conditions
• History of spontaneous pneumothorax.
Individuals who
have experienced spontaneous pneumothorax should avoid
diving, even after a surgical procedure designed to prevent
recurrence (such as pleurodesis). Surgical procedures either
do not correct the underlying lung abnormality (e.g.: pleurode-
sis, apical pleurectomy) or may not totally correct it (e.g.: resec-
tion of blebs or bullae).
• Impaired exercise performance due to respiratory disease.
GASTROINTESTINAL
Temporary Risks
As with other organ systems and disease states, a process which
chronically debilitates the diver may impair exercise performance.
Additionally, dive activities may take place in areas remote from
medical care. The possibility of acute recurrences of disability or
lethal symptoms must be considered.
Temporary Risk Conditions
• Peptic Ulcer Disease associated with pyloric obstruction or
severe reflux
• Unrepaired hernias of the abdominal wall large enough to
contain bowel within the hernia sac could incarcerate.
Relative Risk Conditions
• Inflammatory Bowel Disease
• Functional Bowel Disorders
Severe Risks
Altered anatomical relationships secondary to surgery or malfor-
mations that lead to gas trapping may cause serious problems.
Gas trapped in a hollow viscous expands as the divers surfaces
and can lead to rupture or, in the case of the upper GI tract, eme-
sis. Emesis underwater may lead to drowning.
Severe Risk Conditions
• Gastric outlet obstruction of a degree sufficient to produce
recurrent vomiting
• Chronic or recurrent small bowel obstruction
• Severe gastroesophageal reflux
• Achalasia
• Paraesophageal Hernia
ORTHOPAEDIC
Relative impairment of mobility, particularly in a boat or ashore
with equipment weighing up to 18 kgs/40 pounds must be
assessed. Orthopaedic conditions of a degree sufficient to impair
exercise performance may increase the risk.
Relative Risk Conditions
• Amputation
• Scoliosis must also assess impact on respiratory function
and exercise performance.
• Aseptic Necrosis possible risk of progression due to
effects of decompression (evaluate the underlying medical
Page 4 of 6
cause of decompression may accelerate/escalate the pro-
gression).
Temporary Risk Conditions
• Back pain
HEMATOLOGICAL
Abnormalities resulting in altered rheological properties may the-
oretically increase the risk of decompression sickness. Bleeding
disorders could worsen the effects of otic or sinus barotrauma,
and exacerbate the injury associated with inner ear or spinal cord
decompression sickness. Spontaneous bleeding into the joints
(e.g.: in hemophilia) may be difficult to distinguish from decom-
pression illness.
Relative Risk Conditions
• Sickle Cell Disease
• Polycythemia Vera
• Leukemia
• Hemophilia/Impaired Coagulation
METABOLIC AND ENDOCRINOLOGICAL
With the exception of diabetes mellitus, states of altered hormon-
al or metabolic function should be assessed according to their
impact on the individual’s ability to tolerate the moderate exercise
requirement and environmental stress of sport diving. Obesity
may predispose the individual to decompression sickness, can
impair exercise tolerance and is a risk factor for coronary artery
disease.
Relative Risk Conditions
• Hormonal Excess or Deficiency
• Obesity
• Renal Insufficiency
Severe Risk Conditions
The potentially rapid change in level of consciousness asso-
ciated with hypoglycemia in diabetics on insulin therapy or
certain oral hypoglycemic medications can result in drown-
ing. Diving is therefore generally contraindicated, unless
associated with a specialized program that addresses these
issues.
Pregnancy: The effect of venous emboli formed during
decompression on the fetus has not been thoroughly inves-
tigated. Diving is therefore not recommended during any
stage of pregnancy or for women actively seeking to
become pregnant.
BEHAVIORAL HEALTH
Behavioral: The diver’s mental capacity and emotional make-up
are important to safe diving. The student diver must have suffi-
cient learning abilities to grasp information presented to him by
his instructors, be able to safely plan and execute his own dives
and react to changes around him in the underwater environment.
The student’s motivation to learn and his ability to deal with
potentially dangerous situations are also crucial to safe scuba
diving.
Relative Risk Conditions
• Developmental delay
• History of drug or alcohol abuse
• History of previous psychotic episodes
• Use of psychotropic medications
Severe Risk Conditions
• Inappropriate motivation to dive – solely to please spouse,
partner or family member, to prove oneself in the face of
personal fears
• Claustrophobia and agoraphobia
• Active psychosis
• History of untreated panic disorder
• Drug or alcohol abuse
OTOLARYNGOLOGICAL
Equalisation of pressure must take place during ascent and
descent between ambient water pressure and the external audi-
tory canal, middle ear and paranasal sinuses. Failure of this to
occur results at least in pain and in the worst case rupture of the
occluded space with disabling and possible lethal consequences.
The inner ear is fluid filled and therefore noncompressible. The
flexible interfaces between the middle and inner ear, the round
and oval windows are, however, subject to pressure changes.
Previously ruptured but healed round or oval window membranes
are at increased risk of rupture due to failure to equalise pressure
or due to marked overpressurisation during vigorous or explosive
Valsalva manoeuvres.
The larynx and pharynx must be free of an obstruction to airflow.
The laryngeal and epiglotic structure must function normally to
prevent aspiration.
Mandibular and maxillary function must be capable of allowing
the patient to hold a scuba mouthpiece. Individuals who have
had mid-face fractures may be prone to barotrauma and rupture
of the air filled cavities involved.
Relative Risk Conditions
• Recurrent otitis externa
• Significant obstruction of external auditory canal
• History of significant cold injury to pinna
• Eustachian tube dysfunction
• Recurrent otitis media or sinusitis
• History of TM perforation
• History of tympanoplasty
• History of mastoidectomy
• Significant conductive or sensorineural hearing impair-
ment
• Facial nerve paralysis not associated with barotrauma
• Full prosthedontic devices
• History of mid-face fracture
• Unhealed oral surgery sites
• History of head and/or neck therapeutic radiation
• History of temperomandibular joint dysfunction
• History of round window rupture
Severe Risk Conditions
• Monomeric TM
• Open TM perforation
• Tube myringotomy
• History of stapedectomy
• History of ossicular chain surgery
• History of inner ear surgery
• Facial nerve paralysis secondary to barotrauma
• Inner ear disease other than presbycusis
• Uncorrected upper airway obstruction
• Laryngectomy or status post partial laryngectomy
• Tracheostomy
• Uncorrected laryngocele
• History of vestibular decompression sickness
Page 5 of 6
1. Bennett, P. & Elliott, D (eds.)(1993).
The Physiology and Medicine
of Diving
. 4th Ed., W.B. Saunders Company Ltd., London, England.
2. Bove, A., & Davis, J. (1990).
Diving Medicine
. 2nd Edition, W.B.
Saunders Company, Philadelphia, PA.
3. Davis, J., & Bove, A. (1986). “Medical Examination of Sport Scuba
Divers, Medical Seminars, Inc.,” San Antonio, TX
4. Dembert, M. & Keith, J. (1986). “Evaluating the Potential Pediatric
Scuba Diver.” AJDC, Vol. 140, November.
5. Edmonds, C., Lowry, C., & Pennefether, J. (1992) .3rd ed.,
Diving
and Subaquatic Medicine
. Butterworth & Heineman Ltd., Oxford,
England.
6. Elliott, D. (Ed) (1994). “ Medical Assessment of Fitness to Dive.”
Proceedings of an International Conference at the Edinburgh Con-
ference Centre, Biomedical Seminars, Surry, England.
7. “ Fitness to Dive,” Proceedings of the 34th Underwater & Hyperbaric
Medical Society Workshop (1987) UHMS Publication Number
70(WS-FD) Bethesda, MD.
Paul A. Thombs, M.D., Medical Director
Hyperbaric Medical Center
St. Luke’s Hospital, Denver, CO, USA
Peter Bennett, Ph.D., D.Sc.
Professor, Anesthesiology
Duke University Medical Center
Durham, NC, USA
pbennett@dan.duke.edu
Richard E. Moon, M.D., F.A.C.P., F.C.C.P.
Departments of Anesthesiology and Pulmonary
Medicine
Duke University Medical Center
Durham, NC, USA
Roy A. Myers, M.D.
MIEMS
Baltimore, MD, USA
William Clem, M.D., Hyperbaric Consultant
Division Presbyterian/St. Luke’s Medical Center
Denver, CO, USA
John M. Alexander, M.D.
Northridge Hospital
Los Angeles, CA, USA
Des Gorman, B.Sc., M.B.Ch.B., F.A.C.O.M.,
F.A.F.O.M., Ph.D.
Professor of Medicine
University of Auckland, Auckland, NZ
d.gorman@auckland.ac.nz
Alf O. Brubakk, M.D., Ph.D.
Norwegian University of Science and Technology
Trondheim, Norway
alfb@medisin.ntnu.no
Alessandro Marroni, M.D.
Director, DAN Europe
Roseto, Italy
Hugh Greer, M.D.
Santa Barbara, CA, USA
hdgblgfpl@aol.com
BIBLIOGRAPHY/REFERENCE
ENDORSERS
Page 6 of 6
8. Neuman, T. & Bove, A. (1994). “ Asthma and Diving.” Ann. Allergy,
Vol. 73, October, O’Conner & Kelsen.
9. Shilling, C. & Carlston, D. & Mathias, R. (eds) (1984).
The
Physician’s Guide to Diving Medicine
. Plennum Press, New York,
NY.
10. Undersea and Hyperbaric Medical Society (UHMS)
www
.UHMS.org
11. Divers Alert Network (DAN) United States, 6 West Colony Place,
Durham, NC www.DiversAlertNetwork.org
12. Divers Alert Network Europe, P.O. Box 64026 Roseto, Italy, tele-
phone non-emergency line: weekdays office hours +39-085-893-
0333, emergency line 24 hours: +39-039-605-7858
13. Divers Alert Network S.E.A.P., P. O. Box 384, Ashburton, Aus-
tralia, telephone 61-3-9886-9166
14. Divers Emergency Service, Australia, www.rah.sa.gov.au/hyper-
baric, telephone 61-8-8212-9242
15. South Pacific Underwater Medicine Society (SPUMS), P.O. Box
190, Red Hill South, Victoria, Australia, www.spums.org.au
16. European Underwater and Baromedical Society, www.eubs.org
Christopher J. Acott, M.B.B.S., Dip. D.H.M.,
F.A.N.Z.C.A.
Physician in Charge, Diving Medicine
Royal Adelaide Hospital
Adelaide, SA 5000, Australia
Chris Edge, M.A., Ph.D., M.B.B.S., A.F.O.M.
Nuffield Department of Anaesthetics
Radcliffe Infirmary
Oxford, United Kingdom
cjedge@diver.demon.co.uk
Richard Vann, Ph.D.
Duke University Medical Center
Durham, NC, USA
Keith Van Meter, M.D., F.A.C.E.P.
Assistant Clinical Professor of Surgery
Tulane University School of Medicine
New Orleans, LA, USA
Robert W. Goldmann, M.D.
St. Luke’s Hospital
Milwaukee, WI, USA
Paul G. Linaweaver, M.D., F.A.C.P.
Santa Barbara Medical Clinic
Undersea Medical Specialist
Santa Barbara, CA, USA
James Vorosmarti, M.D.
6 Orchard Way South
Rockville, MD, USA
Tom S. Neuman, M.D., F.A.C.P., F.A.C.P.M.
Associate Director, Emergency Medical Services
Professor of Medicine and Surgery
University of California at San Diego
San Diego, CA, USA
Yoshihiro Mano, M.D.
Professor
Tokyo Medical and Dental University
Tokyo, Japan
y.mano.ns@tmd.ac.jp
Simon Mitchell, MB.ChB., DipDHM, Ph.D.
Wesley Centre for Hyperbaric Medicine
Medical Director
Sandford Jackson Bldg., 30 Chasely Street
Auchenflower, QLD 4066 Australia
smitchell@wesley.com.au
Jan Risberg, M.D., Ph.D.
NUI, Norway
Karen B.Van Hoesen, M.D.
Associate Clinical Professor
UCSD Diving Medicine Center
University of California at San Diego
San Diego, CA, USA
Edmond Kay, M.D., F.A.A.F.P.
Dive Physician & Asst. Clinical Prof. of Family Medicine
University of Washington
Seattle, WA, USA
ekay@u.washington.edu
Christopher W. Dueker, TWS, M.D.
Atherton, CA, USA
chrisduek@aol.com
Charles E. Lehner, Ph.D.
Department of Surgical Sciences
University of Wisconsin
Madison, WI, USA
celehner@facstaff.wisc.edu
Undersea & Hyperbaric Medical Society
10531 Metropolitan Avenue
Kensington, MD 20895, USA
Diver’s Alert Network (DAN)
6 West Colony Place
Durham, NC 27705
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