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.

📄 View PDF Original

Basic Information

Name

Date

Health Check (10 Items)

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

Q1: Did you get enough sleep last night and feel well-rested?

Yes
No

Q2:Do you have a normal appetite today?

Yes
No

Q5: and from

Q3:Are you free from any discomfort or symptoms, such as a hangover?

Yes
No

Q4: Are you free from fever or flu-like symptoms?

Yes
No

Q5: Are you free from diarrhea, dehydration, or related symptoms?

Yes
No

Q6: Are you free from numbness in your limbs or pain anywhere in your body?

Yes
No

Q7: Are you free from dizziness or lightheadedness?

Yes
No

Q8:Are your ears and sinuses clear, and can you equalize your ears without difficulty?

Yes
No

Q9: Have you fully recovered from your previous dive, with no lingering fatigue or body aches?

Yes
No

Q10:Do you feel physically and mentally ready and willing to dive today?

Yes
No

Declaration

I have reviewed the above precautions and declare that I have no issues with any of the items listed and that I am able to dive safely of my own volition.

Signature (Please sign so your name is legible)

署名をクリアー