Medical Statement and Questionnaire

WERSJA ŹRÓDŁOWA

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PLPolskiSSI Diver Medical · 3 strony GBEnglishSSI Diver Medical · 3 strony

SSI Diver Medical Participant QuestionnaireWersja źródłowa: 2023-09-18 · oryginał pozostaje niezmienionyOtwórz PDF

DANE WRAŻLIWE

Your medical data is protected

Detailed answers are sensitive data. By default, an instructor sees the document status and whether a physician evaluation is required, not the full answers.

ODIN nie stawia diagnozy i nie zmienia odpowiedzi.
Dokument zachowuje dokładną wersję polskiego albo angielskiego wzoru SSI.
Możesz przerwać przed podpisaniem i wrócić do formularza.

I understand how the data is handled and want to start the questionnaire.

STRONA 1 Z 3

Primary medical screening

Select one answer for every question. Answers are not yet saved to the record.

1I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.

YesNo

2I am over 45 years of age.

YesNo

3I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.

YesNo

4I have had problems with my eyes, ears, or nasal passages/sinuses.

YesNo

5I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

YesNo

6I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

YesNo

7I am currently undergoing treatment, or have required treatment within the last five years, for psychological problems, personality disorder, panic attacks, addiction to drugs or alcohol, or I have been diagnosed with a learning or developmental disability.

YesNo

8I have had back problems, hernia, ulcers, or diabetes.

YesNo

9I have had stomach or intestine problems, including recent diarrhea.

YesNo

10I am taking prescription medications, with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).

YesNo

STRONA 2 Z 3

Additional questions

Complete the indicated additional sections.Only sections triggered by answers on the first page are shown. Every YES answer in this part requires a physician evaluation.

STRONA 1 Z 3 · OŚWIADCZENIE

Statement and signature

Read the statement, confirm your details and sign the form. The signature is not permanently stored yet — this is an ODIN 1.0 workflow simulation.

I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

Participant nameDate of birthSignature date

I have read and understood the participant statement and confirm its contents.

Prefer not to sign digitally?ODIN will prepare a PDF completed with the answers and system data. After printing, only the handwritten signature remains, followed by uploading a scan or clear photos.The English generator will be enabled after its field map is prepared.

Participant signatureSign with your finger, stylus or mouse in the designated area.

Sign with your finger, stylus or mouse in the designated area.