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

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Name

Date

Health Check (10 Items)

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

Q1: I feel fully recovered from my previous dive

Yes
No

Q2: I feel physically fine with no alcohol-related symptoms

Yes
No

Q3: I had sufficient sleep last night

Yes
No

Q4: I have a normal appetite

Yes
No

Q5: My digestion and hydration feel normal

Yes
No

Q6: My hands, feet, and body feel normal — no numbness or pain

Yes
No

Q7: I feel clear-headed with no dizziness

Yes
No

Q8: I feel healthy with no fever or chills

Yes
No

Q9: My ears and sinuses feel clear, and I can equalize normally

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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