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MEDICAL STATEMENT Participant Record (Confidential Information) www.padi.com Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in
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Document Date: 2014-09-30 13:10:42

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City

Denver / Milwaukee / /

Company

Recreational Scuba Training Council Inc. / International PADI Inc. / P.C.C.P. / Medical Seminars Inc. / /

Facility

Plenum Pub / Luke’s Hospital / Pulmonary Medicine Duke University Medical Center / Duke University Medical Center / /

IndustryTerm

cerebral gas embolism / prosthedontic devices / gas emboli / gas trapping / otitis media / respiratory and circulatory systems / organ systems / mountain travel / scuba equipment / subsequent cerebral gas embolization / /

MedicalCondition

loss of consciousness / Intracranial tumor / strokes / cerebral gas embolism / Inflammatory bowel disease / COPD / aneurysm / seizures / Recurrent otitis externa / unconsciousness / decompression sickness / sensorineural hearing impairment / brain injury / prior asthma / bronchitis / alcohol abuse / panic disorder / Recurrent otitis media / agoraphobia / Pneumothorax / heart disease / gastroesophageal reflux / motion sickness / mitral valve prolapse / Peripheral neuropathy / pulmonary overinflation / blackouts / serious injury / significant cold injury / heart attacks / injury / lung disease / obesity / ear disease / residual neurologic deficit / pleural penetration / * previous overinflation injury / Restrictive Disease / Polycythemia / Trigeminal neuralgia / cerebral decompression sickness / Angina / pulmonary overinflation syndrome / sinusitis / blood disorders / Peptic ulcer disease / hypoglycemia / gastrectomy dumping syndrome / back pain / Facial nerve paralysis / Scoliosis / wheezing / Claustrophobia / head injury / upper airway obstruction / asthma / spinal cord injury / Cerebral palsy / Hypertension / bronchospasm / disease / hayfever / gastric outlet obstruction / fainting / pulmonary function / Chronic / diabetes / residual pulmonary air trapping / tension pneumothorax / allergy / hernia / childhood febrile seizures / Inner ear disease / seizure / high cholesterol / pain / migraine headaches / myocardial infarction / reactive airway disease / presbycusis / diabetes mellitus / Sickle cell disease / Aseptic necrosis / epilepsy / Sickle cell trait / high blood pressure / deficiency / Eustachian tube dysfunction / Functional bowel disorders / /

MedicalTreatment

surgery / thoracic surgery / radiation / embolization / insulin therapy / sinus surgery / ear surgery / Amputation / back surgery / heart surgery / chest surgery / /

Organization

Duke University Medical Center Durham / Med Centre / Anesthesiology and Pulmonary Medicine Duke University Medical Center Durham / Surgery Tulane University School / /

Person

Roy A. Myers / James Vorosmarti / Paul G. Linaweaver / Keith Van Meter / Richard E. Moon / Paul A. Thombs / Behavioral / Peter Bennett / /

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Position

Date________________ Physician / care physician Physician / Diver / physician / Medical Director Hyperbaric Medical Center / recreational diver / examining physician / F.A.C.P. Santa Barbara Medical Clinic Undersea Medical Specialist / F.A.C.E.P. Assistant / Professor / /

Technology

radiation / CAD / /

URL

www.padi.com / /

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