Freedive Shetland FS – Health Screening Form

 

Participant Name: ________________________
Date: ________________________

 

Please tick YES or NO to the following questions:

1. Do you have asthma, chronic bronchitis, or any other breathing/lung condition?

2. ☐ YES ☐ NO

3. Do you have any heart or circulation problems (e.g. high blood pressure, angina, irregular heartbeat)?
   ☐ YES ☐ NO

4. Do you suffer from epilepsy, fainting, seizures, or blackouts?
   ☐ YES ☐ NO

5. Have you had any ear, sinus, or nose problems that affect equalisation or diving?
   ☐ YES ☐ NO

6. Have you had recent surgery, injuries, or illnesses that may affect your ability to dive/snorkel?
   ☐ YES ☐ NO

7. Are you currently taking any medication that could affect your safety in water?
   ☐ YES ☐ NO

8. Are you pregnant, or is there a chance you could be pregnant?
   ☐ YES ☐ NO

 

If you answered YES to any of the above, please give details:

Declaration

 

I confirm that the above information is correct and that I take part in this activity at my own risk.

Signature: ________________________  Date: ________________________