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)