Not in use

SCUBADIVING

RecreationalScubadiving: first; renewal
Instructor/Divemaster/Scientist diver
Professional Diver
Divingrelated medical problem

Before booking, pls fill patients selfreportform (below).
If possible - please print on paper to avoid computerdelays.
 

DOCUMENTS needed at the medical visit:
1 e-mail selfreportform (below)
2 ev.valid divers license,
3 divers logbook
4 drivers license or other ID-card.
 

You will find all application forms in the waitingroom but it saves a lot of time if you have them completed before the visit.

SELFREPORTFORM FIRST EXAMINATION
Pls. complete text below, copy and send by e-mail to ame@airmedic.se
In subject field: pls write intended "CPL/PPL/Other  +date of birth yymmdd"
If you don't want to send some answers by e-mail - type "xxxx"!

Date of birth (yymmdd):
Ev. swedish social security (four numbers):
Surname/Family name:
First name:

Permanent address:
Postal address:
E-mailadress:
Telephone home:
Telephone work:
Mobil/Cellular:
 

What to do you want us to do(certificate, medical problem, other)?
Type of certificate/license applied for?

If medical problem what do you think is the cause?
 

Please answer: Yes/No/comments:
Previous medical examination for diving?
Certificate/license held?
Country of issue?
License number?
Limitations/Variations on licence?

Occupation (principal)?
Employer?
Last medical application (ddmmyy):      place:

Have you ever had certificate denied, suspended or revoked?
Expirience of scubadiving/Number of dives?:
Number since last medical?:
Any reported diving incident/accident?:

Any problem with equalisation of ears or sinus?

Do you smoke tobacco: never/date stopped/yes amount:
Alcohol: estimated weekly intake (grams or cl spirit):
Medication last year: name, purpose

GENERAL MEDICAL HISTORY:
Pls answer yes/no/comment!
101 Eye troubles/Eye operation?
102 Spectacles/Contact lenses?
103 Prescription change since last medical?
104 Hay fever or other allergy?
105 Asthma or lungdisease?
106 Heart or vascular trouble?
107 High or low bloodpressure?
108 Kidney stone or visible blood in urine?
109 Diabetes, hormone disorder?
110 Stomach, liver or intestine trouble?
111 Ear disorder, deafness?
112 Nose, throat or speech disorder?
113 Head injury or concussion?
114 Headaches - frequent or severe?
115 Dizziness or faintings spells?
116 Unconsiousness?
117 Neurological disorder: stroke, epilepsy, seizure, paralysis, etc?
118 Psychological/psychiatric trouble of any sort?
119 Alcohol/drug/substance abuse?
120 Attempted suicide?
121 Motion sicness requiring medication?
122 Anemia/Sicle cell trait/ other blood disorder?
123 Malaria or other tropical disease?
124 HIV-test positive (=infected)?
125 Sexually transmitted disease?
126 Admission to hospital?
127 Any other illnes or injury?
128 Visit to medical practitioner since last medical?
129 Refusal of life insurance?
130 Refusal of flying  license
131 no text
132 Medical rejection from or for military service?
133 Award of pension or compensation for injury or illnes?

150 Gynaecologic, or menstrual problems?
151 Are you pregnant?
 

FAMILY HISTORY
unknown?
170 Heart disease?
171 High blood pressure?
High cholesterol levels?
173 Epilepsy?
174 Mental illness?
175 Diabetes?
176 Tuberculosis?
177 Allergy, asthma or eczema?
178 Inherited disorders?
179 Glaucoma?

FAMILY MEMBERS:age+health/disease+age/death and cause of death
unknown?
Father?
Mother?
Brothers/sisters?
Children?