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Medical Form B

 

UK SPORT DIVER MEDICAL CERTIFICATE

 

UK Sport Diver Medical Certificate
CERTIFICATE OF FITNESS TO DIVE
Valid for 5 years to age of 40, 3 years to age of 50 and 1 year thereafter
(May be restricted by Examining Doctor to a shorter period of validity)
This is to Certify that
 
Age : Membership N? :
is in my opinion fit to dive at the time of examination.
Any changes in medical health should be declared.
Date: Valid until :
Signature of Doctor
Address
(or Stamp)

 

 

INSTRUCTIONS TO THE APPLICANT ON THE USE OF THE UK SPORT DIVER MEDICAL FORM

Complete Section A and take this form with you when you attend a diving medical examination. If you are certified fit to dive, the doctor will sign the Certificate of Fitness, which should be cut from the form and shown to your Branch/Club Diving Officer before affixing it in your diver training and qualification record book. If you are referred to a Medical Referee, the doctor will either send this form to the Referee nominated by you, or will return the form to you to take to the Referee when you attend for further examination.
 

SECTION B
To be completed by the examining doctor and may be retained for record purposes
Name of Diver
Height in metres
Weight in kg
BMI
See "General Note"page 1.
  NORMAL?
  YES NO
Ears: R. Drum
Canal
L. Drum
Canal
Sinuses, nose, throat
Chest
Peak Flow
CVS
BP
BP (values) /
Abdomen
CNS
Joints and Limbs
Personality or Mental Disorder
Urine: Free from albumen
Free from sugar
Chest X-ray (Only if indicated - see notes)
Please comment below on any abnormalities (continue on back if further space is required).
Date of Chest X-Ray
(if indicated)
Place
Fit
Unfit
Refer to Referee
Signature of Doctor
Address (or stamp)
 
 
Telephone N?
Date
 
 
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Page last modified: 2nd Nov 2006 - 10:29:41