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MEDICAL STATEMENT Participant Record (Confidential Information) Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct requ
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Document Date: 2006-12-27 00:29:00

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City

Surry / San Antonio / Oxford / Philadelphia / Bethesda / Ashburton / Durham / Denver / Roseto / New York / Victoria / London / /

Company

Recreational Scuba Training Council Inc. / International PADI Inc. / F.C.C.P. / W.B. Saunders Company Ltd. / Butterworth & Heineman Ltd. / Diving Medicine Royal Adelaide Hospital Adelaide SA / 2nd Edition / Plennum Press / Medical Seminars Inc. / 4th Ed. / M.D. / Hyperbaric / /

Continent

North America / /

Country

Australia / United Kingdom / Italy / United States / /

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Facility

Medicine University of Auckland / Luke’s Hospital / Pulmonary Medicine Duke University Medical Center / Anesthesiology Duke University Medical Center / Ph.D. Duke University Medical Center / Luke’s Medical Center / M.D. Northridge Hospital / Family Medicine University of Washington Seattle / Edinburgh Conference Centre / Surgery University of California / Surgical Sciences University of Wisconsin Madison / Dental University / canal History / Prentice Hall / Ph.D. Norwegian University of Science / /

IndustryTerm

cerebral gas embolism / prosthedontic devices / gas density / gas trapping / otitis media / subsequent arterial gas embolization / telephone non-emergency line / respiratory and circulatory systems / organ systems / energy cost / scuba equipment / /

MedicalCondition

Intracranial Tumor / demyelinating disease / cerebral gas embolism / Hypertrophic cardiomyopathy / Other chest disease / decompression illness / seizures / barotrauma Inner ear disease / Pneumothorax / sensorineural hearing impairment Facial nerve paralysis / gastroesophageal reflux / Blackouts / serious injury / injury / Recurrent otitis / Multiple Sclerosis / pulmonary edema / bullae / Angina / blebs / pulmonary overinflation syndrome / blood disorders / Peptic Ulcer Disease / hypoglycemia / Scoliosis / neurologic manifestations / asthma / neurological decompression illness / Gastric outlet obstruction / fainting / recurrent vomiting / Chronic / stroke / Diabetes / tension pneumothorax / alcohol abuse Sickle Cell Disease Polycythemia Vera Leukemia Hemophilia/Impaired Coagulation METABOLIC AND ENDOCRINOLOGICAL With the exception of diabetes mellitus / allergy / childhood febrile seizures / seizure / migraine headaches / exercise Active Reactive Airway Disease / reactive airway disease / coronary artery disease / Aseptic Necrosis / epilepsy / chronic medical conditions / high blood pressure / Deficiency / Interstitial lung disease / disorders / pinna Eustachian tube dysfunction Recurrent otitis media / loss of consciousness / neuromuscular disorders / significant valvular disease / interstitial diseases / Inflammatory Bowel Disease / Aneurysm / unconsciousness / decompression sickness / Structural disorders / Panic attack / lung diseases / bronchitis / Complicated Migraine Headaches / Cerebrovascular Accident / heart disease / personal fears Claustrophobia / Dysentery / motion sickness / Transient Ischemic Attack / Peripheral Neuropathy / pulmonary overinflation / neuromuscular disease / significant cold injury / lung disease / Obesity / Ear disease / Trigeminal Neuralgia / inner ear surgery Facial nerve paralysis / sinusitis / coronary disease / hemophilia / alcoholism / pulmonary air trapping / wheezing / Head injury / Congestive Heart Failure / Hypertension / Active Asthma / spontaneous pneumothorax / disease / Exercise Induced Bronchospasm / hayfever / either structural disorders / spinal cord decompression sickness / Chronic Obstructive Pulmonary Disease / migraine / Hernia / pulmonary barotrauma / high cholesterol / pain / Renal Insufficiency / Myocardial Infarction / diabetes mellitus / heart attack / Edema Restrictive Disease / Previous Overinflation Injury / neurological decompression sickness / cough / respiratory disease / dehydration / /

MedicalTreatment

pleurodesis / surgery / radiation / ear surgery / Back surgery / heart surgery / Thoracic Surgery / embolization / insulin therapy / Sinus surgery / Amputation / spinal surgery / chest surgery / /

Organization

Duke University Medical Center Durham / A.F.O.M. Nuffield Department of Anaesthetics Radcliffe Infirmary Oxford / Diving Medicine Royal Adelaide Hospital Adelaide / UCSD / Duke University / Divers Emergency Service / Tulane University School of Medicine New Orleans / Wesley Centre / Hyperbaric Medical Society / Undersea and Hyperbaric Medical Society / South Pacific Underwater Medicine Society / Norwegian University of Science and Technology / Family Medicine University of Washington Seattle / European Underwater and Baromedical Society / Medical Director Hyperbaric Medical Center St. Luke’s Hospital / University of Auckland / Auckland / University of California at San Diego / Dental University Tokyo / Anesthesiology and Pulmonary Medicine Duke University Medical Center Durham / Surgical Sciences University of Wisconsin Madison / Recreational Scuba Training Council / Tokyo Medical and Dental University / Hyperbaric Consultant Division Presbyterian/St. Luke’s Medical Center Denver / Anesthesiology Duke University Medical Center Durham / /

Person

Injury / Richard E. Moon / Paul A. Thombs / Behavioral / Peter Bennett / Roy A. Myers / William Clem / Vera Leukemia Hemophilia / Tom S. Neuman / Alf O. Brubakk / Edmond Kay / Washington Seattle / John M. Alexander / Van Meter / Sandford Jackson Bldg / Alessandro Marroni / Des Gorman / Paul G. Linaweaver / /

/

Position

family physician Physician / Medicine Medical Director / physician / recreational diver / F.A.C.P. Santa Barbara Medical Clinic Undersea Medical Specialist / Director / Emergency Medical Services / asthmatic diver / Professor / Representative / Professor of Medicine / Diver / F.A.A.F.P. Dive Physician / F.A.C.E.P. Assistant / Governor / Pediatric Scuba Diver / Director / Head / /

ProvinceOrState

New York / Colorado / Maryland / Victoria / Pennsylvania / North Carolina / /

Region

Southern Africa / /

Technology

radiation / CAD / /

URL

www.spums.org.au / www.rah.sa.gov.au/hyperbaric / www.DiversAlertNetwork.org / www.UHMS.org / www.eubs.org / /

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