BRUCE'S SCUBA SCHOOL CLASS FORMS
Ple
ase print or typeNAME ________________________________________________________________________________________
ADDRESS ________________________________________________________________________________________
CITY _____________________________________ STATE/PROVINCE _________ ZIP________________
HOME PHONE___________________________
To the Instructor: If any condition listed on the medical history form in the student record folder is checked by the student, you are required to individually interview the student. If, as a result of the interview, you are unsure whether or not the condition is a contraindication to diver training send the student to a physician for a medical exam. In the event that referral to a physician is necessary, provide the student with this NAUI Medical Form and transfer the student’s medical history and any notes to the copy to take with them to the physician.
To the Physician: This person is an applicant for training in diving with self-contained underwater breathing apparatus (SCUBA). This is an activity which puts unusual stress on the individual in several ways. A list of contraindications is on the reverse of this fo rm for your reference.
The student applicant’s medical history below was provided during the enrollment process.
—— Behavioral health problems —— Bronchitis —— Contact lenses
—— Claustrophobia —— Tuberculosis —— Dental plates
—— Agoraphobia —— Respiratory problems —— Physical disability
—— Migraine headaches —— Back Problems —— Serious injury
—— Epilepsy —— Back/spinal surgery —— Over 40 years old
—— Ear or hearing problems —— Diabetes —— Hepatitis
—— Trouble equalizing pressure —— Ulcers —— HIV positive
—— Sinus trouble —— Colostomy —— Regular medication
—— Severe hayfever —— Hernia —— Drug allergies
—— Heart trouble —— Dizziness or fainting —— Alcohol or drug abuse
—— High blood pressure —— Recent surgery —— Rejected from any activity
—— Angina —— Hospitalized for medical reasons
—— Heart surgery —— Pregnant —— Any medical condition not listed:
—— Asthma —— Motion Sickness _ ______________________________
Notes : PLEASE RETURN THIS FORM TO THE STUDENT APPLICANT Please note that the medical examination form presents a choice under IMPRESSION. We can only accept unconditional approval as stated for student applicants desiring to begin or continue training. If you conclude that diving is not in the individual’s best interest or that their medical condition is likely to present a probable direct threat to others, please discuss your opinion with the person and check disapproval. IMPRESSION: ___ APPROVAL (I find no medical conditions I consider incompatible with diving.) ___ DISAPPROVAL ( This applicant has medical conditions which in my opinion clearly would constitute unacceptable hazards to health and safety in diving.)Date ________________________ Signature __________________________________________________________________ , MD.
Physician’s Name (print) _________________________________________________________________________________________
Address_____________________________________________________________________________________________________
Phone _________________________________________________________
TM
MEDICAL EVALUATIONAND PHYSICIAN APPROVAL FORM.This list of relative and absolute contraindications is not all inclusive. Contraindications that are absolute permanently place the diver and his diving partners at increased risk for injury or death. Relative contraindications to scuba may be resolved with time and proper medical intervention or may be intermit-tent. A bibliography is included to aid in clarifying issues that arise. The Divers Alert Network (DAN) physicians are available for consultation by phone (919) 684-2948 during normal business hours. For diving related emergencies call, DAN at (919) 684-8111 24 hours, 7 days a week.
OTOLARYNGOLOGICAL
Relative Contraindications:• History of...–significant cold injury to pinna–TM perforation–tympanoplasty –mastoidectomy–mid-face fracture–head and/or neck therapeuticradiation–temporomandibular joint dysfunction • Recurrent otitis externa• Significant obstruction of theexternalauditory canal• Eustachian tube dysfunction • Recurrent otitis media or sinusitis• Significant conductive or sensorineural hearing impairment • Facial nerve paralysis not associated with barotrauma • Full prosthodontic devices • Unhealed oral surgery sites
Absolute Contraindications: • History of... –stapedectomy –ossicular chain surgery –inner ear surgery–round window rupture –vestibular decompression sickness • Monomeric TM • Open TM perforation • Tube myringotomy • Facial nerve paralysis secondary to barotrauma • Inner ear disease other than presbycusis • Uncorrected upper airway obstruction • Laryngectomy or status post partial laryngectomy • Tracheostomy • Uncorrected laryngocele
NEUROLOGICAL Relative Contraindications: • History of...–head injury with sequelae other than seizure–spinal cord or brain injury without residual neurologic deficit –cerebral gas embolism without residual, pulmonary air trapping has been excluded • Migraine headaches whose symptoms or severity impair motor or cognitive function • Herniated nucleus pulposus • Peripheral neuropathy • Trigeminal neuralgia • Cerebral palsy in the absence of seizure activity
Absolute Contraindications: • History of...–seizures other than childhood febrile seizures–TIA or CVA –spinal cord injury, disease or surgery with residual sequelae–Type II (serious and/or central nervous system) decompression sickness with permanent neurologic deficit • Intracranial tumor or aneurysm
CARDIOVASCULAR Relative Contraindications: The suggested minimum criteria for stress testing is 13METS.• History of...–CABG or PCTA for CAD –myocardial infarction–dysrhythmia requiring medicationfor suppression• Hypertension • Valvular regurgitation• Asymptomatic mitral valve prolapse• Pacemakers-Note: Pacemakers must be depth certified by the manufacturer to at least 130feet (40 meters) of sea water.
Absolute Contraindications: • Asymmetric sepal hypertrophy and valvular stenosis • Congestive heart failure
PULMONARY Asthma (reactive airway disease), COPD cystic or cavitating lung diseases all may lead to air trapping.
Relative Contraindications: • History of...–prior asthma or reactive airway disease (RAD)*–exercise/cold induced bronchospasm (EIB)–solid, cystic or cavitating lesion• Pneumothorax secondary to: thoracic surgery *, trauma or pleural penetration*, previous over inflation injury* • Restrictive Disease** (*Air Trapping must be excluded) (**Exercise Testing necessary) Absolute Contraindications: • History of spontaneous pneumothorax • Active RAD (asthma), EIB, COPD or history of the same with abnormal PFS or positive challenge • Restrictive diseases with exercise impairment
GASTROINTESTINAL Relative Contraindications: • Peptic ulcer disease • Inflammatory bowel disease • Malabsorption states • Functional bowel disorders • Post gastrectomy dumping syndrome • Paraesophageal or hiatal hernia
Absolute Contraindications: • High grade gastric outlet obstruction • Chronic or recurrent small bowel obstruction • Entrocutaneous fistulae that do not drain freely • Esophageal diverticula • Severe gastroesophageal reflux• Achalasia • Unrepaired hernias of the abdominal wall potentially containing bowel
METABOLIC AND ENDOCRINOLOGI-CAL Relative Contraindications: • Hormonal excess or deficiency • Obesity • Renal insufficiency
Absolute Contraindications: • Diabetics on Insulin therapy or orar anti-hypoglycemia medication
PREGNANCY Absolute Contraindications: Venous gas emboli formed during decompres-sion may result in fetal malformations. Diving is absolutely contraindicated during any state of pregnancy.
HEMATOLOGICALRelative Contraindications: • Sickle cell trait • Acute anemia
Absolute Contraindications:• Sickle cell disease• Polycythemia• Leukemia
ORTHOPEDIC Relative Contraindications: Chronic Back Pain Amputation Scoliosis - assess impact on pulmonary function Aseptic osteonecrosis
BEHAVIORAL HEALTH
Relative Contraindications: • History of–drug or alcohol abuse–previous psychotic episodes• Developmental delay
Absolute Contraindications: • History of panic disorder• Inappropriate motivation for scuba training • Claustrophobia and agoraphobia • Active psychosis or while receiving psychotropic medications • Drug or alcohol abuse
Read all above and still would
___ APPROVAL (I find no medical conditions I consider incompatible with diving.)
___ DISAPPROVAL ( This applicant has medical conditions which in my opinion
Date ________________________ Signature_____________________________________________________________ , MD.
BIBLIOGRAPHY
The Physiology and Medicine of Diving, 4th edition, 1993; Diving and Subaquatic Medicine, 3rd edition 1994; Diving Physiology in Plain English, 2nd edition, 1997 TM
CONTRAINDICATIONS TO DIVING
NAUI Statement of Understanding and Student LearningAgreement for Skin and Scuba Diving Training
The diving course you are about to begin is an exciting and demanding challenge. It will allow you to eventually explore the "other three-fourths" of our planet that is underwater. To accept the call of underwater adventure, you must be aware of the risks involved in the sport and be willing to study and practice to achieve success.
This course will require heavy physical exertion. You will need to be able to equalize pressure in your ears and sinuses. Your breathing and circulatory systems must also be in good health. You will need to complete a medical history form and your instructor may require you to be examined by a physician. You will also need to read, discuss and sign a waiver, release and indemnity agreement, and this document. If you are a minor, you will need to have this form and your medical form signed by a parent. These forms are returned to the instructor for the course files.
Skin and scuba diving are equipment sports. Some equipment is personal and needs to be purchased. Other equipment can be rented or will be provided during the course. Do not purchase equipment until it has been discussed in class and you know how to evaluate your purchases.
The
cost of this course is: $240.00
standard rate $340 Semi Private$440 Private
Makeup is $25 an hr + expenses (travel/loging/food)
Course includes Instruction in the pool and study review sessions. All pool gear ( Fins, Mask, Snorkel, Scuba Air Tanks, Regulator, Buoyancy compensator (BC), Submersible pressure gauge (SPG), Dive Computer, and Air Fills for pool classes) will be provided.
Free for lifetime scuba review on any full class taken and completed with A Bruce's SCUBA School.Free weight belt replacement for life if belt needs to be ditched in an emergency no questions asked.
Additional costs in order to complete the course will be: Student kit $49.95 + tax and if warm water referral is not wanted you will need personal gear (Mask $30-$130, Snorkel $24-$49, Gloves $35-$65, Boots $35-$65, Fins $89-$199) & $6 parking , food , logging, transportation to and from dive site. You will need to purchase the following equipment: if warm water referral is wanted:
personal gear (Mask $30-$130, Snorkel $24-$49). Optional items: (Gloves $35-$65 Boots $35-$65 Fins $89-$199) and or rental Gloves, Boots, Fins, 2 Scuba Air Tanks, Regulator, BC. SPG./Dive Computer, Compass, Wet or Dry suit & hood $100-$150
It should cost approximately: $190-$1500 you will need to add it up depending on what you buy or rent range is $190.00 to $500 to $1500 Important information is included in every course session. Because diving is built from a few basics to more complex concepts, you must attend every session or your training will be incomplete. You will be required to make up any missed sessions.( Makeup cost is $25 an hr + expenses) Bring paper and pencil to take notes in class. Your notes will help you study for the classroom evaluations. You will need to successfully complete a final examination and successfully demonstrate all required skills in the pool and in open water in order to be certified.
Open water training sessions are subject to the instructor’s assessment of environmental conditions and will be consoled only during site evaluations, but you can plan on making 8 open water dives that are tentatively scheduled for: The Break Water in Monterey The 1st dive starting at 7 am Saturday finishing the 2nd dive by 4pm. Sunday we meet at Monastery beach past Carmel starting time is 7am.for the 3rd dive finishing the 4th dive by 4pm. DO NOT BE LATE! we may move if we can not dive there. We meet for the 5th dive at The Break Water in Monterey again but this time later in the day 3pm for the last dive to be certified. If you look and act like a diver your 6th dive is a night dive. On Sunday as a bubby team we meet at Monastery beach 7am DO NOT BE LATE! we may move if we can not dive there. I will watch you as a certified diver just to make sure you can do it all with out any help from me.
NAUI Worldwide has developed diver education systems to help you study and become familiar with diving terminology and understand the concepts and physical laws that apply to skin and scuba diving. Complete education systems have been packaged for each level of training. For example, the NAUI Scuba Diver Education System for the NAUI Scuba Diver Course contains a textbook, workbook, dive tables, log book, plus a video and audio tape presentation of the academic content. Everything you need to pre-study or review the academic material, in a format that is consistent with your dominant learning style, is contained in the system. Whether assigned in conjunction with scheduled classroom sessions or as a whole, the education systems approach to diver training will help you be a better diver. You may purchase yours at: BRUCE'S SCUBA SCHOOL FOR DISCOUNT PRICE (only with instruction) $49.95 RETAIL($69.95)
I understand and agree that by enrolling in this course I am incurring obligations for attendance, skill performance and financial responsibility. I understand and agree that mastering the subject matter and skills of skin and scuba diving are largely dependent on me, that my instructor is only able to assist and guide me as I proceed through the training process and that my accounts with the facility and/or the instructor must be settled before I will receive my NAUI certification card. I also understand and agree that learning to skin or scuba dive requires a commitment of time, money, cooperation and practice in order to be certified.
I am willing to accept the risks and responsibilities for my own actions. I understand that the instructor must make the final judgment as to my
competency to be a safe diver and be awarded certification.
Signed __________________________________________________ Date. _______________________
Parent's of Minor _________________________________________ Date. _______________________
CALL 650-96SCUBA OR 650-967-2822 E-mail BRUCE'S SCUBA SCHOOL
Copyright © 2004 A Bruce's SCUBA School . All rights reserved .