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Chapter 4 — 6
MEDICAL CHECKLIST
FOR SNORKELLERS
Have you ever had any of the following medical conditions :
1. Any cardiovascular disease?
(Heart, blood pressure, blood, etc).
YES
NO
2. Any lung disease?
(Asthma, wheezing, pneumothorax, TB, etc.)
YES
NO
3. Any fits, epilepsy, convulsions or blackouts?
YES
NO
4. Any serious disease? (Such as diabetes)
YES
NO
5. Serious ear, sinus or eye disease?
YES
NO
6. Any neurological or psychiatric disease?
YES
NO
7. Any family history of heart disease?
YES
NO
Over the last month have you had any of the following :
8. Operations, illnesses, treatment?
YES
NO
9. Drugs or medications?
YES
NO
10. If female, are you pregnant?
YES
NO
11. Can you swim 500 metres without aids?
NO
YES
12. Can you swim 200 metres in 5 minutes or less?
NO
YES
NAME :
DoB :
ADDRESS :
(If under 16 years, guardian to sign.)
Note : If the candidate indicates an answer in the left hand column, then further
investigation or action is required before snorkelling is considered as safe.