TANDEM STUDENT PARACHUTIST Medical Questionnaire
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1 TANDEM STUDENT PARACHUTIST Medical Questionnaire my Name: DOB: Today s Date:
2 Contents Introduction Key Client Information Important notes Vision assessment Health questionnaire Nervous system Diabetes mellitus - Blood sugar Psychiatric illness - nerves Heart health Coronary artery disease - chest pains Peripheral arterial disease excluding Buerger s disease), aortic aneurysm/dissection Valvular/congenital heart disease Other heart problems Heart investigations Blood pressure General health Additional information Declaration About CountryHealth 2
3 Introduction Thank you for choosing us to arrange my Tandem Student Parachutist medical examination. In order to help us complete the official forms, please answer all questions to the best of my knowledge and believe. Skydiving is a risk sport where there is always a small but definite risk of death, injury or worsening of a pre-existing medical condition. This questionnaire is designed to help us identify whether you may be at greater than normal risk. If you have one of these conditions, it does not necessarily mean that you cannot jump but you should first seek qualified medical advice and certification, using BPA form 115B. 3
4 Key Client Information my Name Address Post code DOB Daytime tel. no. address NHS GP Name NHS GP Address Important notes Please bring with you copies of relevant hospital notes. Please bring with you details of all current medication. 4
5 Health questionnaire Please put a tick next to each question that applies to you and provide further information at the end of the questionnaire. Nervous system I have a history of, or evidence of a neurological disorder: I have had any form of seizure I am currently on anti-epileptic medication I have had a brain scan I I have had an EEG I have had a Stroke or TIA I have made a full recovery I have had a carotid ultrasound I have had a sudden and disabling dizziness/vertigo within the last year with a liability to recur I have had a subarachnoid haemorrhage I have had a serious traumatic brain injury within the last 10 years I have had a form of brain tumour I have had brain surgery I suffer from any chronic neurological disorder I have Parkinson s disease There is a history of blackout or impaired consciousness within the last 5 years I suffer from narcolepsy 5
6 Diabetes mellitus - Blood sugar I don t have diabetes mellitus Ys, I I have diabetes mellitus, and take Insulin take a Sulphonylurea or a Glinide take oral hypoglycemic agents and diet treat my diabetes with diet only Have had hypoglycaemia in the last 12 months requiring the assistance of another person Suffer from a loss of visual field Suffer from severe peripheral neuropathy, sufficient to impair limb function Have had laser treatment or intravitreal treatment for retinopathy Psychiatric illness - nerves I don t have a psychiatric illness There is a history of, or evidence of, psychiatric illness, drug/alcohol misuse within the last 3 years I have suffered from a significant psychiatric disorder within the past 6 months I have had a psychosis or hypomania/mania within the past 12 months, including psychotic depression I suffer from dementia or cognitive impairment I have suffered from Persistent alcohol misuse in the past 12 months Alcohol dependence in the past 3 years Persistent drug misuse in the past 12 months Drug dependence in the past 3 years 6
7 Heart health Coronary artery disease - chest pains I have no history of chest pains There is a history of, or evidence of, coronary artery disease I have suffered from angina I have suffered from an acute coronary syndrome including myocardial infarction I have had a coronary angioplasty (P.C.I.) I have had a coronary artery bypass gra surgery Cardiac arrhythmia - irregular heart beats I have no history of irregular heart beats There is a history of, or evidence of, cardiac arrhythmia Has there been a significant disturbance of my heart rhythm i.e. sinoatrial disease, significant atrioventricular conduction defect, atrial flutter/fibrillation, narrow or broad complex tachycardia in the last 5 years The arrhythmia has been controlled satisfactorily for at least 3 months A defibrillator (ICD) or biventricular pacemaker (CRT-D type) has been implanted A pacemaker has been implanted I am free of the symptoms that caused the device to be fitted I attend a pacemaker clinic regularly Peripheral arterial disease excluding Buerger s disease), aortic aneurysm/dissection There is no history of peripheral arterial disease There is a history of, or evidence of, peripheral arterial disease (excluding Buerger s disease), or aortic aneurysm/dissection I suffer from peripheral arterial disease (excluding Buerger s disease) I have claudication I have an aortic aneurysm It has been repaired successfully The transverse diameter is currently > 5.5 cm I have had a dissection of the aorta successfully repaired There is a history of Marfan s disease 7
8 Valvular/congenital heart disease There is no history of a heart disease There is a history of congenital heart disease There is a history of heart valve disease There is a history of aortic stenosis There is any history of embolism I currently have significant symptoms Other heart problems There is NO history of other heart problems There is a history of, or evidence of heart failure I have established cardiomyopathy Has a le ventricular assist device (LVAD) been implanted I have had a heart or heart/lung transplant I suffer from untreated atrial myxoma Heart investigations I never had any cardiac investigations Cardiac investigations have been undertaken or are planned A resting ECG has been undertaken; If YES, does it show:- pathological Q waves le bundle branch block right bundle branch block An exercise ECG has been undertaken (or planned) An echocardiogram has been undertaken (or planned) The le ejection fraction is greater than or equal to 40% A coronary angiogram has been undertaken or planned A 24 hour ECG tape has been undertaken (or planned) A myocardial perfusion scan or stress echo study has been undertaken (or planned) 8
9 Blood pressure I am on blood pressure treatment No YES, these are three previous readings [with dates if available] 1. / on: 2. / on: 3. / on: General health I am currently fit and well There is currently some functional impairment There is a history of bronchogenic carcinoma or other malignant tumour with a significant liability to metastasise cerebrally [in the brain] There is an illness that may cause significant fatigue I am profoundly deaf But I am able to communicate in the event of an emergency I have a history of liver disease There is a history of kidney failure There is a history of, or evidence of, obstructive sleep apnoea syndrome or any other medical condition causing excessive sleepiness I have severe symptomatic respiratory disease causing chronic hypoxia [lack of oxygen] I have an ophthalmic [eye] condition I have another medical condition 9
10 Declaration I DECLARE AND CONFIRM THAT: I am in robust physical health and am able to exercise and move my limbs without restriction. I understand that being unfit, being overweight for my height or having frailty of aging will render me more prone to injury. I am not receiving any regular repeat medication, whether tablets, liquids, injections, patches or inhalers (the contraceptive pill can be ignored for the purposes of this section). I do not have a recurrent need to use painkillers. I have never received prolonged courses of steroids or high dose steroid treatment in the past. I do not have joint, back, sciatic or neck problems and have not been prone to these in the past. I have never had fractured or broken bones. I have NEVER dislocated or partially dislocated a shoulder. I have not had torn tendons, ligaments or cartilages. I do not have weakness or paralysis of any limb. I have not had partial or complete loss of any limbs. I do not have rheumatism, arthritis or arthrosis. I do not have any form of heart disease. I have never had a heart attack, myocardial infarction, coronary disease, angina, ischaemic heart disease, heart valve problems, heart failure, irregular pulse, palpitations, chest pain on exercising, peripheral vascular disease, Hypertrophic Cardiomyopathy (HOCM), cardiac pacemaker, aneurysm. I do not have a family history of sudden death at an early age. I do not have raised blood pressure or hypertension. If over 40 years of age, I understand that blood pressure problems are o en silent and painless at first and that I should have had a blood pressure check with a qualified professional within the last five years. I do not have any form of lung disease and can exercise vigorously without wheeze or unusual breathlessness. I have not been diagnosed with asthma, emphysema, chronic bronchitis, Chronic Obstructive Pulmonary Disease (COPD), fibrotic lung disease, pulmonary embolism (clot on the lung), pneumothorax (collapsed lung), Cystic Fibrosis, obstructive sleep apnoea. I do not use inhalers, nebulisers or ventilators. I have not had a chest infection or pneumonia within the last 3 months. I do not have any form of colostomy, ileostomy, urostomy, catheter, PEG, reservoir or other drainage, collection, infusion, shunt or pump device. I do not have any surgical implants or artificial joints. I have not had any surgical procedures within the last 3 months. I have not received an organ transplant. I do not suffer from anaemia, Thalassaemia, Sickle Cell disease or bleeding disorders such as stomach or bowel haemorrhage, haemophilia, ITP or Von Willebrand s Disease. I have never had a serious head injury or fractured skull. I do not have epilepsy or fits and have not suffered from recurrent giddiness, dizziness, faints, blackouts or loss of consciousness. I do not have Cerebral Palsy, myositis, Muscular Dystrophy, Multiple Sclerosis, Parkinsons Disease 10
11 or any other progressive disease of the brain or nervous system. I have never had a stroke, subarachnoid haemorrhage (SAH), transient ischaemic attack (TIA) or Vertebrobasilar Insufficiency (VBI). I do not suffer from disabling headaches. I do not have diabetes. I do not have any form of endocrine or hormonal disease or deficiency such as thyroid or adrenal problems. I have never been diagnosed with osteopenia or osteoporosis (reduced bone strength). I do not have a history of drug or alcohol dependence. I do not have anxiety, panic attacks, depression or post-traumatic stress disorder and have neither needed to see a doctor nor needed any treatment for any of these in the last 2 years. I have never been diagnosed as having psychosis, schizophrenia, manic-depressive psychosis, bipolar disease or any other serious mental illness. I do not have a history of self-harming behaviour or suicide attempts. I do not have significant learning difficulties, behavioural problems, ADHD, mental subnormality, Down s Syndrome (Trisomy 21) or any other form of trisomy. I do not have any problems with my memory. I have not been diagnosed as suffering from Dementia, Alzheimer s Disease, or significant cognitive impairment. I do not have sinus or ear disease. I do not suffer from ear or sinus pain in aircra. I understand that colds or sore throats may make me temporarily unfit to skydive because they increase the risk of ear or sinus pain or damage. I have not been diagnosed as having cancer in any form. I have not donated blood in the last 6 months, or if I have donated within the last 6 months I have had a subsequent blood test showing my blood count is still normal. I am not on sick leave and am not currently certified as unfit for work. I do not receive any form of sickness benefit, disability benefit or attendance allowance. I have not received a terminal diagnosis. I am not waiting for the results of any tests or investigations. I am not under medical review for any problems. To the best of my knowledge, I am not pregnant. I have no problems with seeing or hearing, or if I have such problems I will ensure that my instructors are fully aware of them. I do not have any form of infectious disease such as hepatitis, HIV or tuberculosis, which may be transmitted by body fluids. I understand that, due to the direction and speed of airflow, my tandem instructor may be exposed to my saliva, blood or vomit in the course of even a normal parachute jump. I declare that I have checked the details I have given on the enclosed questionnaire and that, to the best of my knowledge and belief, they are correct. Name: Signature: Date: 11
12 About CountryHealth Private GP Practice - We specialise in Thyroid Health and Functional / Nutritional Medicine Our patients usually get in touch when they need help that the NHS cannot provide. We can advise you on symptoms, organise specialist tests that are o en not available on the NHS and can also refer you privately to specialists. We want to find the root cause of my problems, not just cover the symptoms with medication. As a private medical patient, you can expect more personal, friendly consultations and appointments at times that suit YOU. To fully explore my concerns, we don t limit you to one problem per 10 minute appointment. Instead our appointments take typically minutes. Unfortunately, we cannot offer A&E services. Our approach is different. We want to find the root cause of my problems, not just cover the symptoms with medication. We offer a range of services to our clients to help them to Get Well and Stay Well. Health Screenings Genetic Testing Nutritional / Functional Therapy Food Intolerance Testing Bowel Cancer Screening To find out more, please visit our website: Practice: CountryHealth Cornwallis Chambers 23 Great Colman Street Ipswich IP4 2AN Phone : reception@countryhealth.co.uk 12
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