Medical Histoy Form

Required for every course

Medical form

To take part in any Harry’s Dive Shop scuba or snorkeling class, you must download, complete and sign the SSI Medical Statement, and return it to us before the start of the course.

Fill it out correctly

The Medical History must be filled out a very specific way in order to be valid.

■ You must physically write out the words YES or I to each and every question.

■ You cannot simply put a Y or an N, or use checkmarks or Xs.

■ If you make mistake, you must start over from scratch. You cannot white-out or cross out and initial any answer or fill-in blank.


Make your life easier


By far the fastest and best way to complete this form is to save it to your computer and then re-open it in Adobe Acrobat. Acrobat will allow you to complete and save the form on screen — it will even allow you to answer those tedious Yes/No questions from a dropdown menu.

When you are finished, just click on the Signature field and Acrobat will walk you through how to sign the form digitally. Then all you have to do is save the form and email it back to us.

If you can’t use Acrobat

Print the form on the front and back of a single sheet of paper (it is not valid if printed on two separate sheets). Be sure to fill out the contact information on the top half of the back. Assuming you can honestly answer NO to all of the questions, bring the signed form to the shop prior to class.


What if I have to answer YES?

Don’t panic. It just means that you have a condition that requires a physician’s approval prior to taking part in any in-water activities. Here is what you do:

■ Take the completed Medical History form to your physician, along with the Guidelines for Recreational Scuba Diver’s Physical Examination.

■ Discuss the medical history/exam form and guidelines with your physician. If he or she has a question, the guidelines have a number at Duke University Medical Center you can call.

Assuming your physician is okay with you diving (which is generally the case), he or she can sign the form where indicated on the back. Bring the signed form with you when you arrive for class.