FD-1065a.pdf

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Attached to
RFP - Medical Evaluations and Services Federal contract opportunity
Solicitation number
15F06725R0000538
Issued by
Department of Justice Federal Bureau of Investigation

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The document is an FBI Diving Medical History Addendum (Form FD-1065a) dated 08/19/2025, designed to comprehensively document a diver's medical history and neurological examination. The form includes detailed sections for medical screening, including a comprehensive checklist of potential diving-related medical issues such as gas embolism, oxygen toxicity, ear problems, and decompression illness. It requires a thorough neurological examination covering cranial nerves, reflexes, cerebellar function, muscle strength, proprioception, sensations, and range of motion, with spaces to mark normal or abnormal findings for each assessed area. The final section includes a body diagram for documenting altered sensations, surgical scars, and traumatic injuries, to be completed and signed by a medical examiner.

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FD-1065a 08/19/2025

FEDERAL BUREAU OF INVESTIGATION

FBI DIVING MEDICAL HISTORY ADDENDUM

Last Name First Name Middle Name Date

1. When diving, have you ever experienced any of the following (each item marked as “yes” must be fully explained with dates in 4 below by question number):

Yes No Yes No

Gas embolism Near Drowning

Oxygen toxicity Inability to equalize middle ear pressure

CO2 toxicity Vertigo (dizziness)

Ear and/ or sinus squeeze Asphyxiation

Collapsed lung (pneumothorax) or lung squeeze Type I DCS (pain only, itching, rash, swelling)

Nitrogen narcosis Type II DCS

Loss of consciousness Decompression illness (symptoms of both

AGE/DCS)

Ear drum rupture Any other unusual symptoms

2. Other medical condition(s) not listed above:

Neurologic Examination (Each item must be completed)

3. Sensorium (Consciousness/intellectual/cognitive function):

4. Cranial Nerves:

I. Olfactory VII. Facial

II. Optic VIII. Auditory

III. Oculomotor IX. Glossopharyngeal

IV. Trochlear X. Vagus

V. Trigeminal XI. Spinal Accessory

VI. Abducent XII. Hypoglossal

5. Reflexes

Deep Tendon (Grade 0-4+ 2+ = Normal)

Left Right

Triceps

Biceps

Patella

Achilles

Pathological (+/- = presence/absence)

Left Right

Babinski

Hoffman

Ankle Clonus

Superficial (+/- = presence/absence)

Upper Abdomen

Lower Abdomen

Cremasteric

FD-1065a - 1 -

FEDERAL BUREAU OF INVESTIGATION

FBI DIVING MEDICAL HISTORY ADDENDUM

6. Cerebellar Function

Normal Abnormal

Alaxia

Tremor (intention)

Finger to nose

Heel to shin slide

Romberg sign

7. Proprioception/Steregonsis (+/1 = presence/absence)

Left Right

Joint position sense

Vibratory sensations

Agnosia (ability to recognize objects by touch)

8. Sensations (+/- = presence/absence)

Hot/Cold

Sharp/dull

Two point discrimination

9. Nystagmus (+/- = presence/absence)

End point (physiologic) Pathological

10. Muscle Strength (Grade 0-5.5 = normal)

Upper Body Left Right

Delliods

Latissimus

Biceps

Triceps

Forearms

Hands

Fingers

Lower Body Left Right

Hips

Flexion

Extension

Abduction

Adduction

Knees Left Right

Flexion

Extension

Ankles

Dorsiflexion

Plantarflexion

Toes

11. Range of Motion (+/- = normal, abnormal)

Left Right

Shoulders

Elbows

Wrists

Hips

Knees

Ankles

FD-1065a - 2 -

FEDERAL BUREAU OF INVESTIGATION

FBI DIVING MEDICAL HISTORY ADDENDUM

12. Diagram and label area of altered sensations, surgical and traumatic scars.

Examiner’s Name Signature Date

FD-1065a - 3 -

Date
Middle Name
First Name
Last Name
Last Name:
First Name:
Middle Name:
Date:
Gas embolism: Off
Oxygen toxicity: Off
CO2 toxicity: Off
Ear and/or sinus squeeze: Off
Collapsed lung: Off
Nitrogen narcosis: Off
Loss of consciousness: Off
Ear drum rupture: Off
Near drowning: Off
Inability to equalize middle ear pressure: Off
Vertigo: Off
Asphyxiation: Off
Type I DCS: Off
Type II DCS: Off
Decompression illness: Off
Any other unusual symptoms: Off
Other medical condition(s):
Sensorium:
I Olfactory:
II Optic:
III Oculomotor:
IV Trochlear:
V Trigeminal:
VI Abducent:
VII Facial:
VIII Auditory:
IX Glossopharyngeal:
X Vagus:
XI Spinal Accessory:
XII Hypoglossal:
Left Patella:
Right Patella:
Left Achilles:
Right Achilles:
Left Babinski:
Right Babinski:
Left Hoffman:
Right Hoffman:
Left Ankle Clonus:
Right Ankle Clonus:
Upper Abdomen:
Lower Abdomen:
Cremasteric:
Normal Alaxia:
Abnormal Alaxia:
Normal Tremor:
Abnormal Tremor:
Normal Finger to nose:
Abnormal Finger to nose:
Normal Heel to shin slide:
Abnormal Heel to shin slide:
Normal Romberg Sign:
Abnormal Romberg Sign:
Left Joint position sense:
Right Joint position sense:
Left Vibratory sensations:
Right Vibratory sensations:
Left Agnosia:
Right Agnosia:
HotCold:
Sharpdull:
Two point discrimination:
End point physiologic:
Pathological:
Left Delloids:
Right Delloids:
Left Latissimus:
Right Latissimus:
Left Biceps:
Right Biceps:
Left Triceps:
Right Triceps:
Left Forearms:
Right Forearms:
Left Hands:
Right Hands:
Left Fingers:
Right Fingers:
Left Hips:
Right Hips:
Left Flexion:
Right Flexion:
Left Extension:
Right Extension:
Left Abduction:
Right Abduction:
Left Adduction:
Right Adduction:
Left Flexion1:
Right Flexion1:
Left Extension1:
Right Extension1:
Left Ankles:
Right Ankles:
Left Dorsiflexion:
Right Dorsiflexion:
Left Plantarflexion:
Right Plantarflexion:
Left Toe:
Right Toe:
Left Shoulders:
Right Shoulders:
Left Elbows:
Right Elbows:
Left Wrists:
Right Wrists:
Left Hips1:
Right Hips1:
Left Knees:
Right Knees:
Left Ankles1:
Right Ankles1:
Examiner's Name:
Signature Date:
HotCold1:
Sharpdull 1:
Two point discrimination 1:
Left Biceps 2:
Right Biceps 2:
Left Triceps 2:
Right Triceps 2:

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