Diver’s Medical Record

This form is for use alongside MA1 and for retention with MA2 and any additional clinical notes.

Diver details

Name	Date of birth

Address

AMED details

Name	HSE PIN number

Address

Date of examination and AMED’s signature

Date of examination	Signature
Year 1
Year 2
Year 3
Year 4
Year 5

Diving history

Medical history

Medication

Allergies

General medical considerations

Year 1	Year 2	Year 3	Year 4	Year 5
Smoking status
Alcohol consumption
Height (m)
Weight (kg)
BMI (kg/m2)
Waist circumference (cm)
Risk assessment for exercise testing satisfactory
VO2 max (ml/kg/min)

Respiratory system

Year 1	Year 2	Year 3	Year 4	Year 5
Air entry
Percussion note
Added sounds
FEV1
FVC
FEV1/FVC ratio
PEF
PEF or FEV1 5 min post exercise
PEF or FEV1 10 min post exercise
PEF or FEV1 15 min post exercise

Cardiovascular system

Year 1	Year 2	Year 3	Year 4	Year 5
Pulse
BP (mmHg)
ECG (as required)
Heart sounds
Murmur(s)
Peripheral pulses and circulation
Varicose veins

Nervous system

Cranial nerves

Year 1	Year 2	Year 3	Year 4	Year 5
II-XII

Peripheral nerves

Year 1	Year 2	Year 3	Year 4	Year 5
Tone
Power

Reflexes

Year 1	Year 2	Year 3	Year 4	Year 5
Biceps
Triceps
Supinator
Knee
Ankle
Plantar

Sensation

Year 1	Year 2	Year 3	Year 4	Year 5
Light touch
Pinprick
Temperature
Two-point discrimination
Proprioception
Vibration

Other findings

Year 1	Year 2	Year 3	Year 4	Year 5
Appearance
Posture
Gait
Balance
Coordination
Involuntary movements
Speech

Mental health

Year 1	Year 2	Year 3	Year 4	Year 5
Mental state assessment

Musculoskeletal system

Year 1	Year 2	Year 3	Year 4	Year 5
Spine
Upper limbs
Lower limbs

ENT

Year 1	Year 2	Year 3	Year 4	Year 5
R	L	R	L	R	L	R	L	R	L
Audiometry (as required)
External meatus
Tympanic membranes
Eustachian tube function
Nasal airways

Vision

Year 1	Year 2	Year 3	Year 4	Year 5
R	L	R	L	R	L	R	L	R	L
Distance vision
Near vision
Visual fields
Fundi (as required)
Colour vision (as required)

Dental health

Year 1	Year 2	Year 3	Year 4	Year 5
Regular dental assessments

Endocrine system

Year 1	Year 2	Year 3	Year 4	Year 5
Evidence of endocrine disease

Abdomen

Year 1	Year 2	Year 3	Year 4	Year 5
Masses/organomegaly
Evidence of herniae

Urinalysis

Year 1	Year 2	Year 3	Year 4	Year 5
Blood
Protein
Glucose

Skin

Year 1	Year 2	Year 3	Year 4	Year 5
Functionally intact

Haematology

Year 1	Year 2	Year 3	Year 4	Year 5
Haemoglobin (g/l) (as required)

Overall assessment of fitness to dive

Year 1	Year 2	Year 3	Year 4	Year 5
Fit/unfit
Restrictions

Abnormalities/additional findings

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[Title]

[Subtitle or description]

MA1, diving medical,

Microsoft Office User

2023-05-09

Sarah Spollin

HSE

HSE