MEDICAL STATEMENT

PLEASE PROVIDE ANSWERS TO THE FOLLOWING INQUIRIES REGARDING YOUR MEDICAL HISTORY, BOTH PAST AND PRESENT. ADDITIONALLY, TAKE A MOMENT TO REVIEW THE DETAILS PROVIDED BELOW REGARDING OUR SNORKELING TOUR.

To be read and signed by each participant

Please answer the following questions about your past and current medical history:

A YES or NO must be written for each question
Section 1:
A YES in this section means that unfortunately we cannot take you on our

snorkeling tour for your own safety!

______ Extreme difficulty to perform moderate physical exercise and walk 1 km?

______ Are you pregnant?

______ Any form of lung disease? Pneumothorax (collapsed lung)?

______ Any kind of heart disease?
______ Heart surgery or heart attack in the past 5 years ?
______ Head injury with loss of consciousness in the past 6 months?

______ Colostomy, urostomy or ileostomy?

______ Epilepsy or condition resulting in sudden lost of consciousness?


Section 2: A YES in this section means that you need to get a medical clearance from

a doctor before your tour*. You can find the required medical form of this pdf.

* Medication can not be taken into the water.

______ Under medical care/medication that might affect your ability to perform the tour?

______ High cholesterol, or taking medicine to control it?

______ High or low blood pressure, or taking medicine to control it?
______ Diabetes Mellitus, even controlled by diet alone? Taking medication for diabetes?

______ Asthma in the past 5 years? Using an inhaler for asthma or respiratory problem?

______ Wheezing when breathing or wheezing with moderate exercise?
______ Behavioral or mental health problems (panic, fear of closed/open spaces)?
______ Back, arm or leg problems following surgery, injury or fracture in the past 4 months? ______ Ulcer or ulcer surgery?
______ Raynaud’s syndrome?
______ Vertigo/dizziness?
______ Cancer in the past 6 months?
______ Your age is 60 or over to 69 ? (the maximum age limit for the tour is 69)