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STATEMENT OF HEALTH FOR RECREATIONAL DIVING
This Section to be completed by the Medical Practitioner.
This is to certify that I have today interviewed and examined:Name........................................................................................................................................................
Address......................................................................................................................................................
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Date of birth................../................./................
Initial those that do and delete those statements that do not apply:
........... I have assessed the candidate in accordance with AS 4005.1.
........... I can find no conditions which are incompatible with compressed gas, scuba and surface supplied breathing apparatus (SSBA) and or breath-hold diving.
............ I have explained the potential health risks of diving to the candidate and we have discussed how these risks may be reduced. The candidate appears to have a good understanding of these risks.
........... Based upon my assessment, the candidate should not dive with compressed gases (Scuba and SSBA).
........... Based upon my assessment, the candidate should not breath-hold dive.
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(Signature of Medical Practitioner) (Name of Medical Practitioner) (Date)
This Section to be completed by the Candidate.
Initial those that do and delete those statements that do not apply:
........... I understand the health risks that I may encounter in diving and how these risks may be reduced. I also understand that the Medical Practitioner's recommendation herewith is based, in part, upon the disclosure of my medical history. I Agree to accept any responsibility and liability for health risks associated with my participation in underwater diving, including those that are due to or are influenced by a change in my health and or my failure to disclose any existing or past health condition to the Medical Practitioner.
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(Signature of Candidate) (Name of Candidate) (Date) | 
