This consolidation is unofficial and is for reference only.  For the official version of the regulations, consult the original documents on file with the Registry of Regulations, or refer to the Royal Gazette Part II.
Regulations are amended frequently.  Please check the list of Regulations by Act to see if there are any recent amendments to these regulations filed with the Registry that are not yet included in this consolidation.
Although every effort has been made to ensure the accuracy of this electronic version, the Registry of Regulations assumes no responsibility for any discrepancies that may have resulted from reformatting.
This electronic version is copyright © 2009, Province of Nova Scotia, all rights reserved.  It is for your personal use and may not be copied for the purposes of resale in this or any other form.


Schedules to the Nova Scotia Offshore Area Petroleum Diving Regulations

made under subsection 146(1) of the
Canada-Nova Scotia Offshore Petroleum Resources
Accord Implementation (Nova Scotia) Act

S.N.S. 1987, c. 3
O.I.C. 96-22 (January 9, 1996), N.S. Reg. 6/96

Schedule I
(Clause 4(4)(a))
Procedures Manual

1 The procedures manual for a diving program shall contain the standard operating procedures to be followed in any diving operation that will be part of the diving program and shall include

(a) the procedures for any consultations with the person in charge of any craft or installation from which the diving operation is conducted;

(b) the procedures to be followed by each person involved in a dive that will be part of the diving program, including a diver, stand-by diver, pilot, attendant and supervisor;

(c) for each depth and each type of dive, the procedures for

(i) conducting the dive, taking into account

(A) local meteorological and sea-state conditions, and

(B) hazards such as strong currents, man-made structures and activities, other than diving, being conducted in the vicinity,

(ii) the selection of the appropriate breathing mixture, decompression tables and treatment tables to be used in the dive,

(iii) the use, inspection and maintenance of the diving plant and equipment, including communications and signalling equipment, to be used in the dive,

(iv) the lowering and recovery of a diver and the launching and recovery of any skip, diving bell, diving submersible or ADS to be used in the dive,

(v) the completion of the diving operations logbook referred to in clause 9(5)(m) and subsection 50(1), including sample entries, and

(vi) the making of a decision to commence, continue, interrupt or discontinue the dive, including any conditions to be taken into account in the determination; and

(d) a sample of the pre-dive checklist to be followed.


Schedule II
(Clause 4(4)(g))
Emergency Procedures

1 (1) The contingency plan for a diving program shall contain the emergency procedures to be followed where circumstances that are likely to endanger a diver or pilot make it impossible and unsafe to follow the procedures contained in the procedures manual for the diving program, such as

(a) deteriorating environmental conditions;

(b) unexpected weather or sea-state conditions;

(c) inability of a craft to maintain itself at the location of the dive site;

(d) evacuation of a craft or installation;

(e) evacuation of divers under pressures greater than atmospheric pressure;

(f) in-water emergency transfers;

(g) failure of any major component of diving plant or equipment; and

(h) fouling of equipment below the surface that impairs the ability of a diver or pilot to complete a dive.

(2) The emergency procedures referred to in subsection (1) shall include procedures for

(a) emergency signalling between divers involved in the diving program and between the divers and their attendants using umbilicals or other suitable methods;

(b) the provision of stand-by divers;

(c) the provision of crafts, stand-by boats and any other devices to be used for rescue;

(d) the provision of first-aid treatment and therapeutic decompression;

(e) the use of the evacuation, rescue and treatment facilities and devices referred to in Section 23 that will be used in the diving program;

(f) contacting the evacuation, rescue and treatment facilities referred to in Section 23 and the medical services referred to in clauses 24(b) and (d) that will be used in the diving program;

(g) the operation of the emergency power supply;

(h) the evacuation of a craft or installation used in the diving program;

(i) the evacuation of divers under pressures greater than atmospheric pressure; and

(j) in-water emergency transfers.


Schedule III
(Clauses 6(1)(i) and (j))
Diving Accident/Incident Report

Name of craft or installation: ____________________ Operator: ______________
Supervisor: _______________________ Diving contractor: __________________
Persons involved: _____________________________ Date: _________________
Type of dive: _______________________________________________________
Purpose of dive: _____________________________________________________
Personal diving equipment used: ________________________________________
Diving plant and equipment used: ________________________________________
Dive profile: Depth: _________________ Bottom time: _______________
Time left surface: ____________ Tables used: ________________
Ascent method: ___________________________________________
Ascent rate & time: ___________ Time returned
to surface: _________________
Name of specialized diving doctor or medical attendant who treated diver or pilot: _________________________________________________
Treatment: Name of diver or pilot
treated: __________________
Treatment table
used: _____________________
Diver's or pilot's medical condition
after treatment: ___________________________________________
Number of dives made by diver or pilot
in the 24 hours preceding accident/incident: _______________________________
Gas mixture(s) used: ___________________
(in dive)
___________________
(in treatment)
Air temperature: ________ Wind speed: ________ Sea state: __________
Type of sea bed: ____________________ Visibility: ______________
Condition of personal equipment after accident/incident: _______________________
Personal equipment examined at: _________________ By: ________________
(Location and date) (Name of examiner)
Summary of accident/incident: _____________________________________
______________________________________________________________
______________________________________________________________

(Use additional sheets as necessary)
_____________________________________
Signature of operator or operator's representative
______________________________
Signature of supervisor


Schedule IV
(Clause 12(2)(b))
Part I - First Aid Supplies for a Diving Operation

Item Column I - Supplies Column II - Details Column III
Quantity
1. Tourniquets -- 2
2. Scissors Mayo, 17,8 cm 1
3. Shell dressings Large 2
4 Surgical gloves Pairs of sizes 8, 9 & 10 2 each
5. Gauze roller bandage Sterile, 5 cm and 7.5 cm, roll 1 each
6. Gauze sponges Sterile, 10 cm x 10 cm, pack of 100 1
7 Adhesive plaster Roll 1
8. Scalpels Disposable, No. 10 & 11 blades 1 each
9 Scalpel blades No. 10 & 11 2 each
10 Laryngoscope Large adult blade, with spare batteries and bulb 1
11 Mouth gag -- 1
12 Mouth to mouth resuscitation tube -- 2
13 Oropharyngeal airways Sizes 3 & 4 1 each
14 Suction apparatus Non-electric (e.g. Ambu foot operated) 1
15 Minor surgical tray Ribbon retractor 1
Army-navy retractor 2
Rake retractor, sharp 1
Rake retractor, blunt 1
Lahey 2
Mosquito hemostat 4
Towel clips 6
Pack, sterile, containing:
- Needle driver 2
- Self-retaining retractor, blunt 1
- Allis 2
- Babcock 2
- Sponge forceps 2
- Scissors, straight Mayo 1
- Scissors, curved Mayo 1
- Scissors, curved Metz 1
- Artery (haemostat) 6
- Kockers 2
- Russian forcep 2
- Knife handle No. 3 1
- Knife handle No. 4 1
- Forceps, toothed 2
- Suction 1
16 Dressing tray Sterile, containing:
- Small cup 1
- Combine pad 1
- Gauze 10 cm x 10 cm 6
- Gauze 5 cm x 5 cm 10
- Dressing towel 1
- Artery forceps 2
- Tissue forceps 1
17 Intravenous-giving sets e.g., Travenol 2C2027 Blood administration set 4
18 Intravenous cannulae Gauges 14, 15 & 16 2 each
19 Intravenous cannula Gauge 16, 20 cm, for central venous placement 1
20 Alcohol injection swabs e.g., Webcol 24
21. Trochar cannulae e.g., Argyle, No. 10, 23 cm 2
22 Heimlich chest drain valves e.g., Bard Parker No. 3460 2
23 Syringes 10 mL 6
24 Syringes 20 mL 6
25. Needles, hypodermic Gauges 16, 21 & 23 6 each
26. Foley bladder catheter 14 & 16 French gauges 1 each
27. Urinary drainage bag -- 1
28. Endotracheal tubes Cuffed, 7 mm, 8 mm, 9 mm & 9.5 mm 1 each
29. Wire introducer For use with endotracheal tubes 1
30. Suction catheters -- 2
31 Blood tubes (not vacutainers) Silicone coated, no additive 2
32 Blood tubes (not vacutainers) Non-silicone coated, EDTA 2
33 Resuscitator bag Laerdal, with 100% 02 fitting and fitting for connection to BIBS 1
34 Xylocaine 1%, without epinephrine, 10 mL 4
35. Xylocaine gel Urethral, 2% tube 1
36 Bridine solution 100 mL, for skin prep 1
37 Dextran 70 (Macrodex) in saline 500 mL 2
38 Dextrose 5% Saline 1000 mL, bag of 4
39. Saline 0.9% 1000 mL, bag of 4
40 Heparin injection 500 /mL, 2 mL vial 1
41 Diazepam injection 10 mg in 2 mL 6
42 Benadryl injection 50 mg in 1 mL 6
43 Furosemide injection 40 mg in 2 mL 6
44. Dexamethasone injection 4 mg, 10 mL vial 2
45 Aspirin tablets 324 mg 50
46 Thermometer, electronic Thermocouple or thermistor 1
47 Stethoscope -- 1
48 Auriscope With spare batteries & bulb 1
49. Reflex hammer -- 1
50 Band Aids Box 1
51 Anaeroid sphygmomanometer -- 1
52 Flashlight With spare batteries & bulb 1
53 Sutures Silk, 3/0 on curved cutting needle 6
54 Sutures Silk, 0/0 on heavy curved needle 6
55 Sutures Chromic catgut, 2/0 on curved taper needle 6
56 Sutures Chromic catgut, 0/0 on curved taper needle 6
57. Ties Silk, 0/0 6
58. Ties Silk, 2/0 6
59. Ties Silk, 3/0 6

Part II
First Aid Supplies to be kept in a Diving Bell or
in the Compression Chamber of a Diving Submersible
Item Column I - Supplies Column II - Details Column III
Quantity
1 Tourniquet -- 1
2 Mouth-to-mouth resuscitation tube -- 1
3. Mouth gag -- 1
4. Oropharyngeal airways -- 2
5. Adhesive plaster Roll 1
6. Band Aids Assorted sizes, flat, box 1
7. Shell dressings Large 2
8. Shell dressings Small 2
9. Scissors Mayo, 17,8 cm 1


Schedule V
(Subclauses 27(b)(ii) and 64(b)(ii))
Supervisor's or ADS pilot's medical examination record

Part I -- To be completed by the physician. Record all abnormal findings on this medical examination record. Circle the correct answer as required.

Family name: ____________________ First name(s): ____________________
Birth date: ____________________ Sex: M/F
Ht: _____ cm Wt: _____ kg Identifying features: _______________
___________________________________________________________________
General appearance: __________________________________________________
___________________________________________________________________
HEENT:
Normal? Yes/No
Normal colour vision? Yes/No
Audiometry: Rt. Normal? Yes/No
Lt. Normal? Yes/No
Vision: Distant Distant
with
glasses
Near Near with
glasses
Normal
visual
fields
Normal
Fundi
Right: _______ _______ _______ _______ Yes/No Yes/No
Left: _______ _______ _______ _______ Yes/No Yes/No
Both: _______ _______ _______ _______ Yes/No Yes/No
Skin:
Rash? Yes/No Infection? Yes/No Parasites? Yes/No
Lymph glands normal? Yes/No Breasts normal? Yes/No
RESP:
Any chest scars or deformity? Yes/No
Chest auscultation normal? Yes/No
Any adventitious sounds? Yes/No
Current chest X-ray normal? Yes/No/Not done*
Cardiovascular:
BP ____/____ Pulse: ____/min. Peripheral pulses and circulation normal? Yes/No
Normal apex beat? Yes/No Normal heart sounds? Yes/No
Murmurs present? Yes/No ECG normal? Yes/No
Exercise tolerance test (e.g., Ruffier test) normal? Yes/No
Abdomen:
Organomegaly? Yes/No Masses present? Yes/No Herniae present? Yes/No
Genitourinary system normal? Yes/No Rectal normal Yes/No
Musculo-skeletal:
Spine normal? Yes/No Limbs and joints normal? Yes/No
Central nervous system:
Power & tone of limbs normal? Yes/No
Normal sensation to pinprick? Yes/No
Light touch? Yes/No Temperature? Yes/No Vibration? Yes/No
Proprioception normal? Yes/No
Cranial nerves normal? Yes/No
Reflexes: BJ TJ SJ KJ AJ Abdo. Planter Clonus
Right: _____ _____ _____ _____ _____ _____ _____ _____
Left : _____ _____ _____ _____ _____ _____ _____ _____
Cerebellar function normal? Yes/No Vestibular function normal? Yes/No
Rombergism present? Yes/No Nystagmus present? Yes/No
Lab. Investigations:
Hb: ____g/dL____ HCT: ______________*
Sickle cell trait absent? Yes/No* (initial medical examination)
Blood group: __________ BUN: __________* Creatinine: __________*
Other: ____________________________________________________________
Urine pH: Urine free of: albumin?
sugar?
protein?
blood?
Yes/No
Yes/No
Yes/No
Yes/No
Comment on any abnormalities detected: _________________________________
Is the candidate free from physical defect and disease? Yes/No
Has the candidate the physique for prolonged exertion? Yes/No
Is the candidate fit for work in all climates if inoculations are up-to-date? Yes/No
Is the candidate permanently unfit to dive? Yes/No
Is the candidate temporarily unfit to dive? Yes/No
Date for next examination: __________________________
Is the candidate fit to dive with restrictions? Yes/No Specify: _____________
_______________________________________________________________

* At the discretion of the examining doctor

Name and address of examining doctor: ____________________________
____________________________________________________________

Signed: ____________________ Date: _____________ Place: ____________________

Part II -- To be completed [by the candidate] in ballpoint pen by the supervisor or ADS pilot. Circle the correct answer as required. If in doubt, ask the advice of the examining doctor.

(a) Family name: __________________ First name(s): __________________
Birth date: ____________________ S.I.N.: ________________________
Provincial Health Insurance No.: ______________________________________
(b) Have you had an ADS pilot's medical examination before? Yes/No
If yes, when? __________________ Where? ________________________
(c) Date and place of any X-ray examination: _______________________________
(d)

Give details of vaccinations: _________________________________________
________________________________________________________________
(e) Do you have, or have you ever had or been treated for, any of the following medical conditions?
1.
2.
3.
4.
5.

6.
7.
8.
9.
10.
11
12.
13.
14.
15.
16.
17.

Asthma
Hay fever or allergies
Allergy to drugs/medications
Pneumonia or pleurisy
Bronchitis or other
lung diseases
Tuberculosis
Sinus trouble
Ear disease
High blood pressure
Rheumatic fever
Heart disease or murmur
Chest pain or palpitations
Bleeding tendency
Skin diseases
Diabetes
Tropical diseases
Fits, blackouts or epilepsy
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

18.
19.
20.
21.
22.

23.
24.

25.
26.
27.
28.
29.
30.

31.

32.
33.

Dizziness, loss of balance
Head injury or concussion
Stroke or paralysis
Severe headache or migraine
Nervous breakdown or
mental illnesses
Eye disorders
Stomach/duodenal/peptic
ulcer
Gall bladder disorder
Diarrhoea or bowel disease
Jaundice or hepatitis
Kidney or bladder disease
Bone/joint disease or injury
Back injury or chronic
back pain
Other serious illness or
injury
Motion sickness
Varicose veins
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No
Yes/No

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No

Yes/No
Yes/No

Give details of any positive answers, including dates: __________________
_____________________________________________________________
(f) Give date and place of any hospital admissions or operations: ___________
_____________________________________________________________
(g) Have you been under medical treatment during the past year? Yes/No
If yes, for what? _______________________________________________
(h) Are you taking, or have you ever taken, any medicines or drugs? Yes/No
If yes, specify: _________________________________________________
(i) If you smoke, how many cigarettes do you smoke? ____/day
If you drink alcohol, how many glasses of wine ____/week, of beer ____/week
and of spirits ____/week do you drink?
Have you ever used any mind-altering, "street" or addictive drugs? Yes/No
If yes, give details: _____________________________________________
_____________________________________________________________

I, (name) ____________________, of (address) _______________________________,

declare that all of the above information is true to the best of my knowledge and I give my permission for this information to be communicated to other doctors concerned with my well-being.

Signed: __________________ Date: ___________ Place: __________________

Part III -- Physician's Statement

Doctor's remarks: ______________________________________________
_____________________________________________________________

Candidate's logbook inspected? Yes/No

If "no", state reason: ____________________________________________

Signed: _______________________ M.D.
Dated: ________________________


Schedule VI
(Subclauses 28(1)(a)(iii), 30(1)(a)(iii) and 32(1)(a)(iii))
Recommendation for Category _____ Diving Supervisor's Certificate

This is to certify that ___________________, born on _______________, _______ at ________________, presently working for _____________________, as a category ____,
is familiar with all the aspects of diving practice and supervision of that category ____,
as specified under the Nova Scotia Offshore Area Petroleum Diving Regulations. Therefore, I/we, the undersigned, have no hesitation in recommending this applicant as a category ____ diving supervisor and, to the best of my/our knowledge and belief, I/we state that I/we know the applicant sufficiently and that I am/we are not aware of any reason why the applicant should not be granted the above-mentioned status.

1. Diving
supervisor:
_____________________
(please print name)
Category: ____ From: ______________
(Date)
Signature: ______________________ Date: ____________________________
2. Diving
supervisor:
_____________________
(please print name)
Category: ____ From: ______________
(Date)
Signature: ______________________ Date: ____________________________
3. Diving contractor or operator: _________________________________
(please print name)
Signature: ______________________ Date: ____________________________


Schedule VII
(Subclause 53(b)(iii))
Diver's Medical Examination Record

Part I -- To be completed by the physician. All abnormal findings shall be recorded on the diver's medical examination record. Circle the correct answer as required.

Family name: ____________________ First name(s): ____________________
Birth date: _______________________ Sex: M/F
Ht: ______ cm Wt: ______ kg Identifying features: _______________
____________________________________________________________________
General appearance: ___________________________________________________
____________________________________________________________________
HEENT:
Normal? Yes/No URTI: Normal? Yes/No
Teeth & gums normal? Yes/No Any dentures? Yes/No
Neck normal? Yes/No Sinuses normal? Yes/No
Dental X-rays normal? Yes/No/Not done* Normal colour vision? Yes/No
Nasal
airway
EAM Eardrums Eustacian
tube
Audiometry
Rt. Normal? Yes/No Yes/No Yes/No Yes/No Yes/No
Lt. Normal? Yes/No Yes/No Yes/No Yes/No Yes/No
Vision: Distant Distant
with
glasses
Near Near with
glasses
Normal
visual
fields
Normal
Fundi
Right: ________ ________ ________ ________ Yes/No Yes/No
Left: ________ ________ ________ ________ Yes/No Yes/No
Both: ________ ________ ________ ________ Yes/No Yes/No
Skin:
Rash? Yes/No Infection? Yes/No Parasites? Yes/No
Lymph glands normal? Yes/No
Skinfold thickness: Lt. biceps: ____ mm Lt. triceps: ____ mm
Lt. subcaphular: ____ mm Lt. sacroiliac: ____ mm Breasts normal? Yes/No
RESP:
Any chest scars or deformity? Yes/No
Chest auscultation normal? Yes/No
Any adventitious sounds? Yes/No
Current chest X-ray normal? Yes/No FVC:FEV1/FVC%: ______%
Cardiovascular:
BP ____/____ Pulse: _____/min. Varicose veins? Yes/No
Peripheral pulses and circulation normal? Yes/No
Normal apex beat? Yes/No Normal heart sounds? Yes/No
Murmurs present? Yes/No ECG normal? Yes/No
Exercise tolerance test (e.g., Ruffier test) normal? Yes/No
Stress ECG normal? Yes/No/Not done+
Abdomen:
Organomegaly? Yes/No Masses present? Yes/No Herniae present? Yes/No
Genitourinary system normal? Yes/No Rectal normal Yes/No
Musculo-skeletal:
Joint x-rays*: Shoulders Hip Knees
Rt. normal? Yes/No Yes/No Yes/No
Lt. normal? Yes/No Yes/No Yes/No
Spine normal? Yes/No Limbs and joints normal? Yes/No
Central nervous system:
Power & tone of limbs normal? Yes/No Normal sensation to pinprick? Yes/No
Cranial nerves normal? 1.
2.
3.
4.
5.
6.
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
7.
8.
9.
10.
11.
12.
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Reflexes: BJ TJ SJ KJ AJ Abdo. Planter Clonus
Right:
Left:
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Cerebellar function normal? Yes/No Vestibular function normal? Yes/No
Rombergism present? Yes/No Nystagmus present? Yes/No
EEG normal? Yes/No/Not done* Electronystagmograms normal Yes/No/Not done*
Lab. Investigations:
Hb: ____g/dL____ HCT: ______________*
Sickle cell trait absent? Yes/No* (initial medical examination)
Blood group: __________ BUN: __________* Creatinine: __________*
Other: ____________________________________________________________
Urine pH: Urine free of: albumin?
sugar?
protein?
blood?
Yes/No
Yes/No
Yes/No
Yes/No
Comment on any abnormalities detected: _________________________________
Is the candidate free from physical defect and disease? Yes/No
Has the candidate the physique for prolonged exertion? Yes/No
Is the candidate fit for work in all climates if inoculations are up-to-date? Yes/No
Is the candidate permanently unfit to dive? Yes/No
Is the candidate temporarily unfit to dive? Yes/No
Date for next examination: _______________________________
Is the candidate fit to dive with restrictions? Yes/No Specify: ______________
________________________________________________________________

* At the discretion of the examining doctor

+ Mandatory for divers 35 years of age

Name and address of examining doctor: _________________________________
_________________________________________________________________

Signed: ___________________ Date: __________ Place: ____________________

Part II -- To be completed by the diver in ballpoint pen. Circle the correct answer as required. If in doubt, ask the advice of the examining doctor.

(a) Family name: _____________________ First name(s): _____________________
Birth date: _______________________ S.I.N.: ___________________________
Provincial Health Insurance No.: ________________________________________
(b) Have you had a commercial diver's medical examination before? Yes/No
If yes, when? _____________________ Where? _____________________
When did you first work under pressure? ____________________________
(c) Date and place of your last bone and joint X-ray examination: _________________
Other x-ray examinations: _____________________________________________
Give details of vaccinations: ___________________________________________
(d) Have you ever had any of the following medical problems?
1.
2.
3.
4.
5.
6.
7.
8.
9.
Skin bends?
Limb bends?
Spinal or cerebral bends?
Pulmonary decompression sickness?
Vestibular bends?
Pulmonary barotrauma (ruptured lung)?
Arterial gas embolism?
Problems with compression?
Dysbaric osteonecrosis (bone necrosis)?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Give details of any positive answers, including dates and number of times the problem has occurred: _______________________________________________
(e) Do you have, or have you ever had or been treated for, any of the following medical conditions?

1.
2.
3.
4.
5.
6.

7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Asthma
Hay fever or allergies
Allergy to drugs/medications
Pneumothorax
Pneumonia or pleurisy
Bronchitis or other
lung diseases
Tuberculosis
Sinus trouble
Ear disease
Rheumatic fever
Heart disease or murmur
Chest pain or palpitations
Varicose veins
Bleeding tendency
Skin diseases
Diabetes
Tropical diseases
Fits, blackouts or epilepsy
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

19.
20.
21.
22.

23.
24.
25.
26.
27.
28.
29.
30
31.

32.
33.


34.

Head injury or concussion
Stroke or paralysis
Severe headache or migraine
Nervous breakdown or
mental illnesses
Eye disorders
Stomach/duodenal/peptic ulcer
Gall bladder disorder
Diarrhoea or bowel disease
Jaundice or hepatitis
Venereal disease
Toothache, dental problems
Bone/joint disease or injury
Back injury or chronic
back pain
Other serious illness or injury
Females: gynaecological
disease or medical problems
related to pregnancy
Motion sickness
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No
Yes/No


Yes/No

Give details of any positive (Yes) answers, including dates: ________________
________________________________________________________________
(f) Give date and place of any hospital admissions or operations: ______________
________________________________________________________________
(g) Have you been under medical treatment during the past year? Yes/No
If yes, for what? _____________________________________________
(h) Are you taking, or have you ever taken any medicines or drugs? Yes/No
If yes, specify: _______________________________________________
(i) If you smoke, how many cigarettes do you smoke? _____/day
If you drink alcohol, how many glasses of wine _____/week, of beer _____/week
and of spirits _____/week do you drink?
Have you ever used any mind-altering, "street" or addictive drugs? Yes/No
If yes, give details: ____________________________________________

I, (name) _______________________ , of (address) ___________________________,
declare that all of the above information is true to the best of my knowledge and I give my permission for this information to be communicated to other doctors concerned with my welfare.

Signed: _____________________ Date: __________ Place: _____________________

Part III -- Physician's Statement

Doctor's remarks: _______________________________________________
______________________________________________________________

Diver's logbook inspected? Yes/No

If "no", state reason: ______________________________________________

Signed: _________________________ M.D.
Dated: __________________________