18-Specification and Requirements Attachment B, Divers Physical GEN2130705B1, Occupational Med Srvcs-Drug Alcohol Testing.pdf

ATTACHMENT B

DIVING MEDICAL EXAM OVERVIEW FOR THE EXAMINING PHYSICIAN

TO THE EXAMINING PHYSICIAN:

This person, _____________________, requires a medical examination to assess their fitness for certification as a Scientific Diver for the_______________________ (Organizational Member). Their answers on the Diving Medical History Form (attached) may indicate potential health or safety risks as noted. Your evaluation is requested on the attached SCUBA Diving Fitness Medical Evaluation Report. If you have questions about diving medicine, you may wish to consult one of the references on the attached list or contact one of the physicians with expertise in diving medicine whose names and phone numbers appear on an attached list, the Undersea Hyperbaric and Medical Society, or the Divers Alert Network. Please contact the undersigned Diving Safety Officer if you have any questions or concerns about diving medicine or the __________________________ standards. Thank you for your assistance. Organizational Member Diving Safety Officer Date

Printed Name Phone Number

SCUBA and other modes of compressed-gas diving can be strenuous and hazardous. A special risk is present if the middle ear, sinuses, or lung segments do not readily equalize air pressure changes. The most common cause of distress is eustachian insufficiency. Recent deaths in the scientific diving community have been attributed to cardiovascular disease. Please consult the following list of conditions that usually restrict candidates from diving.

(Adapted from Bove, 1998: bracketed numbers are pages in Bove)

CONDITIONS WHICH MAY DISQUALIFY CANDIDATES FROM DIVING

1. Abnormalities of the tympanic membrane, such as perforation, presence of a monomeric membrane, or inability to autoinflate the middle ears. [5 ,7, 8, 9]

2. Vertigo, including Meniere’s Disease. [13]

3. Stapedectomy or middle ear reconstructive surgery. [11]

4. Recent ocular surgery. [15, 18, 19]

5. Psychiatric disorders including claustrophobia, suicidal ideation, psychosis, anxiety states, untreated depression. [20 - 23]

6. Substance abuse, including alcohol. [24 - 25]

7. Episodic loss of consciousness. [1, 26, 27]

8. History of seizure. [27, 28]

9. History of stroke or a fixed neurological deficit. [29, 30]

10. Recurring neurologic disorders, including transient ischemic attacks. [29, 30]

11. History of intracranial aneurysm, other vascular malformation or intracranial hemorrhage. [31]

12. History of neurological decompression illness with residual deficit. [29, 30]

13. Head injury with sequelae. [26, 27]

14. Hematologic disorders including coagulopathies. [41, 42]

15. Evidence of coronary artery disease or high risk for coronary artery disease. [33 - 35]

16. Atrial septal defects. [39]

17. Significant valvular heart disease - isolated mitral valve prolapse is not disqualifying. [38]

18. Significant cardiac rhythm or conduction abnormalities. [36 - 37]

19. Implanted cardiac pacemakers and cardiac defibrillators (ICD). [39, 40]

20. Inadequate exercise tolerance. [34]

21. Severe hypertension. [35]

22. History of spontaneous or traumatic pneumothorax. [45]

23. Asthma. [42 - 44]

24. Chronic pulmonary disease, including radiographic evidence of pulmonary blebs, bullae, or cysts. [45,46]

25. Diabetes mellitus. [46 - 47]

26. Pregnancy. [56]

SELECTED REFERENCES IN DIVING MEDICINE

Available from Best Publishing Company, P.O. Box 30100, Flagstaff, AZ 86003-0100, the Divers Alert Network (DAN) or the Undersea and Hyperbaric Medical Society (UHMS), Durham, NC

● Elliott, D.H. ed. 1996. Are Asthmatics Fit to Dive? Kensington, MD: Undersea and Hyperbaric Medical

Society.

● Bove, A.A. 2011. The cardiovascular system and diving risk. Undersea and Hyperbaric Medicine 38(4):

261-269.

● Thompson, P.D. 2011. The cardiovascular risks of diving. Undersea and Hyperbaric Medicine 38(4): 271-277.

● Douglas, P.S. 2011. Cardiovascular screening in asymptomatic adults: Lessons for the diving world. Undersea and Hyperbaric Medicine 38(4): 279-287.

● Mitchell, S.J., and A.A. Bove. 2011. Medical screening of recreational divers for cardiovascular disease:

Consensus discussion at the Divers Alert Network Fatality Workshop. Undersea and Hyperbaric Medicine 38(4): 289-296.

● Grundy, S.M., Pasternak, R., Greenland, P., Smith, S., and Fuster, V. 1999. Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations. AHA/ACC Scientific Statement. Journal of the American College of Cardiology, 34: 1348-1359. http://content.onlinejacc.org/cgi/content/short/34/4/1348

● Bove, A.A. and Davis, J. 2003. DIVING MEDICINE, Fourth Edition. Philadelphia: W.B. Saunders Company.

● Edmonds, C., Lowry, C., Pennefather, J. and Walker, R. 2002. DIVING AND SUBAQUATIC MEDICINE, Fourth Edition. London: Hodder Arnold Publishers.

● Bove, A.A. ed. 1998. MEDICAL EXAMINATION OF SPORT SCUBA DIVERS, San Antonio, TX: Medical

Seminars, Inc.

● NOAA DIVING MANUAL, NOAA. Superintendent of Documents. Washington, DC: U.S. Government Printing

Office.

● U.S. NAVY DIVING MANUAL. Superintendent of Documents, Washington, DC: U.S. Government Printing

Office, Washington, D.C.

http://content.onlinejacc.org/cgi/content/short/34/4/1348

AAUS MEDICAL EVALUATION OF FITNESS FOR SCUBA DIVING REPORT

Name of Applicant (Print or Type) Date of Evaluation (Month/Day/Year)

To The Examining or Supervising Physician: Scientific divers require periodic SCUBA diving medical examinations to assess their fitness to engage in diving with self-contained underwater breathing apparatus (SCUBA). Their answers on the Diving Medical History Form may indicate potential health or safety risks as noted. SCUBA diving is an activity that puts unusual stress on the individual in several ways. Your evaluation is requested on this Medical Evaluation form. Your opinion on the applicant's medical fitness is requested. SCUBA diving requires heavy exertion. The diver must be free of cardiovascular and respiratory disease (see references, following page). An absolute requirement is the ability of the lungs, middle ears and sinuses to equalize pressure.

Any condition that risks the loss of consciousness should disqualify the applicant. Please proceed in accordance with the AAUS Medical Standards (Sec. 5.00). If you have questions about diving medicine, please consult with the Undersea Hyperbaric Medical Society or Divers Alert Network.

NOTE: Although portions of this exam may be conducted by other medical professionals (P.A. or N.P.), final signature for diving must come from a Medical Doctor (M.D.) or Osteopath (D.O.).

TESTS: THE FOLLOWING TESTS ARE REQUIRED:

DURING ALL INITIAL AND PERIODIC RE-EXAMS (UNDER AGE 40):

● Medical history

● Complete physical exam, with emphasis on neurological and otological components

● Urinalysis

● Any further tests deemed necessary by the physician

ADDITIONAL TESTS DURING FIRST EXAM OVER AGE 40 AND PERIODIC RE-EXAMS (OVER AGE 40):

● Chest x-ray (Required only during first exam over age 40)

● Resting EKG

● Assessment of coronary artery disease using Multiple-Risk-Factor Assessment1

(age, lipid profile, blood pressure, diabetic screening, smoking) Note: Exercise stress testing may be indicated based on Multiple-Risk-Factor Assessment1

PHYSICIAN’S STATEMENT:

I have evaluated the above mentioned individual according to the tests listed above. I have discussed with the patient any medical condition(s) that would not disqualify them from diving but which may seriously compromise subsequent health. The patient understands the nature of the hazards and the risks involved in diving with these conditions.

01 I find no medical conditions that may be disqualifying for participation in SCUBA diving.

Diver IS medically qualified to dive for: 2 years (over age 60)

3 years (age 40-59) 5 years (under age 40)

02 Diver IS NOT medically qualified to dive: Permanently Temporarily.

___________________________________________MD or DO _______________________________ Signature Date Name (Print or Type) Address Telephone Number E-Mail Address

My familiarity with applicant is: _____This exam only _____Regular physician for _______ years My familiarity with diving medicine is: ________________________________________________________________

AAUS MEDICAL EVALUATION OF FITNESS FOR SCUBA DIVING REPORT

APPLICANT’S RELEASE OF MEDICAL INFORMATION FORM

Name of Applicant (Print or Type)

I authorize the release of this information and all medical information subsequently acquired in association with my diving to the _____________________________________ Diving Safety Officer and Diving Control Board or their designee at (place) __________________________________________ on (date) ____________________

Signature of Applicant _____________________________________________ Date_____________________

REFERENCES

1 Grundy, S.M., Pasternak, R., Greenland, P., Smith, S., and Fuster, V. 1999. Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations. AHA/ACC Scientific Statement. Journal of the American College of Cardiology, 34: 1348-1359. http://content.onlinejacc.org/cgi/content/short/34/4/1348 http://content.onlinejacc.org/cgi/content/short/34/4/1348

DIVING MEDICAL HISTORY FORM

Name ______________________________________ DOB ____ Age ___ Wt.___ Ht. ___

Sponsor ____________________________________________Date ___/___/___ (Dept./Project/Program/School, etc.) (Mo/Day/Yr)

TO THE APPLICANT:

SCUBA diving places considerable physical and mental demands on the diver. Certain medical and physical requirements must be met before beginning a diving or training program. Your accurate answers to the questions are more important, in many instances, in determining your fitness to dive than what the physician may see, hear or feel as part of the diving medical certification procedure.

This form must be kept confidential by the examining physician. If you believe any question amounts to invasion of your privacy, you may elect to omit an answer, provided that you must subsequently discuss that matter with your own physician who must then indicate, in writing, that you have done so and that no health hazard exists.

Should your answers indicate a condition, which might make diving hazardous, you will be asked to review the matter with your physician. In such instances, their written authorization will be required in order for further consideration to be given to your application. If your physician concludes that diving would involve undue risk for you, remember that they are concerned only with your well-being and safety.

Yes No Please indicate whether or not the following apply to you Comments

1 Convulsions, seizures, or epilepsy

2 Fainting spells or dizziness

3 Been addicted to drugs

4 Diabetes

5 Motion sickness or sea/air sickness

6 Claustrophobia

7 Mental disorder or nervous breakdown

8 Are you pregnant?

9 Do you suffer from menstrual problems?

10 Anxiety spells or hyperventilation

11 Frequent sour stomachs, nervous stomachs or vomiting spells

12 Had a major operation

13 Presently being treated by a physician

14 Taking any medication regularly (even non-prescription)

15 Been rejected or restricted from sports

16 Headaches (frequent and severe)

17 Wear dental plates

18 Wear glasses or contact lenses

19 Bleeding disorders

20 Alcoholism

21 Any problems related to diving

22 Nervous tension or emotional problems

Yes No Please indicate whether or not the following apply to you Comments

23 Take tranquilizers

24 Perforated ear drums

25 Hay fever

26 Frequent sinus trouble, frequent drainage from the nose, post-nasal drip, or stuffy nose

27 Frequent earaches

28 Drainage from the ears

29 Difficulty with your ears in airplanes or on mountains

30 Ear surgery

31 Ringing in your ears

32 Frequent dizzy spells

33 Hearing problems

34 Trouble equalizing pressure in your ears

35 Asthma

36 Wheezing attacks

37 Cough (chronic or recurrent)

38 Frequently raise sputum

39 Pleurisy

40 Collapsed lung (pneumothorax)

41 Lung cysts

42 Pneumonia

43 Tuberculosis

44 Shortness of breath

45 Lung problem or abnormality

46 Spit blood

47 Breathing difficulty after eating particular foods, after exposure to particular pollens or animals

48 Are you subject to bronchitis

49 Subcutaneous emphysema (air under the skin)

50 Air embolism after diving

51 Decompression sickness

52 Rheumatic fever

53 Scarlet fever

54 Heart murmur

55 Large heart

56 High blood pressure

57 Angina (heart pains or pressure in the chest)

58 Heart attack

Yes No Please indicate whether or not the following apply to you Comments

59 Low blood pressure

60 Recurrent or persistent swelling of the legs

61 Pounding, rapid heartbeat or palpitations

62 Easily fatigued or short of breath

63 Abnormal EKG

64 Joint problems, dislocations or arthritis

65 Back trouble or back injuries

66 Ruptured or slipped disk

67 Limiting physical handicaps

68 Muscle cramps

69 Varicose veins

70 Amputations

71 Head injury causing unconsciousness

72 Paralysis

73 Have you ever had an adverse reaction to medication?

74 Do you smoke?

75 Have you ever had any other medical problems not listed? If so, please list or describe below;

76 Is there a family history of high cholesterol?

77 Is there a family history of heart disease or stroke?

78 Is there a family history of diabetes?

79 Is there a family history of asthma?

80 Date of last tetanus shot?

Vaccination dates?

Please explain any “yes” answers to the above questions.

I certify that the above answers and information represent an accurate and complete description of my medical history.

Signature Date