Pre-Dive Health Check Form_En | 奄美大島ダイビングショップ LeapScubaAmami (リープスクーバアマミ)

Pre-Dive Health Check Form

This form must be completed by yourself once per day before your first dive.

If you have any physical or mental concerns or notice any changes, please do not hesitate to inform us. Always prioritize safety and refrain from diving if you feel uneasy.

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Basic Information

Name

Date

Health Check (10 Items)

Please confirm that you can answer “Yes” to all items.

Q1: I do not have fatigue or tiredness remaining from the previous dive

Yes
No

and dizziness or

Q2: If I consumed alcohol within the past 12 hours, I am not experiencing any hangover or health issues

Yes
No

Q3: I had sufficient sleep last night

Yes
No

Q4: I have a normal appetite

Yes
No

Q5: I do not have diarrhea or dehydration symptoms

Yes
No

Q6: I do not have numbness in my hands/feet or pain in my body

Yes
No

Q7: I am not experiencing dizziness

Yes
No

Q8: I do not have fever symptoms

Yes
No

Q9: I do not feel any blockage in my ears or sinuses, and I can equalize

Yes
No

Q10: I am motivated and willing to dive

Yes
No

Declaration

I hereby confirm that I have reviewed all of the above items. I declare that I am in good condition and able to dive of my own will.

Signature (Please sign so your name is legible)

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