Survival Apnea Medical Questionnaire

Please read each question carefully and check YES or NO. If you answer YES to any of the questions, please explain any medical conditions to Survival Apnea. Failure to address these conditions prior to engaging in breathing and apnea (breath holding) activity may endanger your health as well as the safety of any person you practice with. A positive answer will not necessarily exclude you from participating in a Survival Apnea course.

1. Neurological: Stroke, brain surgery, severe migraine, significant head injury.

2. Cardiovascular: Heart attack, heart surgery, arrhythmias, hypertension.

3. Pulmonary: Pneumothorax, lung disease, emphysema, pulmonary edema.

4. Ears: Perforated ear-drums, permanent tubes in ear-drums, hearing loss in one or both ears, ear infections, ear surgery.

5. Sinus: Polyps in the sinus cavities, sinus surgery, sinus infection.

6. Asthma: History of asthma attacks, current use of asthma medication.

7. Epilepsy: History of epilepsy.

8. Pregnancy: Currently pregnant or suspected to be pregnant.

9. Medication: Current medication taken on a regular basis.

I certify that I have answered the above questionnaire honestly.

Release of Liability

I certify that I understand that my participation, direct or indirect, in this Survival Apnea course/workshop/training program does not entitle me to any legal rights or action as a result of any accident or incident that should happen during such event.

Furthermore, I understand that breathing and apnea (breath holding) exercises in and out of the water, or any type or form of immersion in the water needed for this event is an inherently dangerous activity.

I also understand that my participation in this event does not entitle me to any kind of compensation or remuneration.

Finally, by signing this document I testify that I will not, under any circumstance, proceed legally against any of the members of Survival Apnea as an organization and/or my instructor/s.

Name:

Date: