Stevens, et al. Appendix 1
Diver telephone triage health questionnaire.
Telephone/ Contact Triage Sheet -Project ID 24772
Subject Number:
1. Are you aged 18 years or over?
2. What was the date of your last dive?
3. Do you currently suffer from any health issues?
4. Are you currently able to exercise at your maximum capacity?
5. Have you ever had or do you now have any health issues or injuries that stopped you diving?
6. Have you had any breathing difficulties in the last 12 months?
7. Do you currently have lung disease, chest infections, asthma, emphysema or excessive shortness of breath when exercising?
8. Have you ever had or do you now experience heart problems, chest pain or palpitations?
9. Do you currently have a respiratory or throat infection, ear clearing problems or sinus pain?
10. Are you currently taking any prescription or over the counter medications? Please define if so
11. Do you suffer from migraines or headaches?
12. Have you experienced any seizures or episodes of loss of consciousness?
13. Are you currently pregnant?
14. Have you experienced any injury, trauma or surgical procedures in the last 12 months?
15. Have you experienced any other health issues not mentioned above?
16. Are you currently completely well?
17. Do you dive 20 or more times per year?
Proceed Y or N ? Study Doctor Sign_____________________Date_______________
