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Personal information and health questionnaire

Intended for the practice of underwater diving activities.
Please complete this questionnaire prior to your dive.

Personal Information

Please type your full name.

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Person to notify in case of emergency

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Your stay on the beautiful atoll of Tikehau

Where are you staying?
Where are you staying?
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Depending on the distance, we will pick you up free of charge by car or boat.
⚠️ Be careful, a 12-hours delay must be respected between your last dive and your departure flight! But you can dive immediately upon arrival 👌🏼

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🐠 DIVING AND YOU 👌🏼

What is your certification level? *
What is your certification level?
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When was the last time you went diving? (approximately)
When was the last time you went diving? (approximately)
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Are you already fully equipped? *
Are you already fully equipped?
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If you have your own BCD please specify it, and if you have your own regulator please specify DIN or not DIN
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Health Information

Ensuring you dive safely
From your certificate of no contraindication to underwater activities or over the last 12 months :

Please answer the questions below by checking the corresponding box. If you are not sure, check YES.
Have you experienced chest pain, palpitations, unusual shortness of breath, or discomfort on exertion? *
Have you experienced chest pain, palpitations, unusual shortness of breath, or discomfort on exertion?
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Has a family member died suddenly from an unexplained cardiac cause? *
Has a family member died suddenly from an unexplained cardiac cause?
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Have you had an episode of wheezing or loss of consciousness? *
Have you had an episode of wheezing or loss of consciousness?
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Have you had a desaturation diving accident? and/or carried out hyperbaric chamber sessions following this incident? *
Have you had a desaturation diving accident? and/or carried out hyperbaric chamber sessions following this incident?
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Do you have bone, muscle or joint pain or problems? *
Do you have bone, muscle or joint pain or problems?
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Have you resumed diving after a break of more than 4 weeks for medical reasons without consulting a doctor? *
Have you resumed diving after a break of more than 4 weeks for medical reasons without consulting a doctor?
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Have you had surgery this year (cardiology, neurology, pulmonology)? *
Have you had surgery this year (cardiology, neurology, pulmonology)?
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Have you recently started taking any new regular prescription medication (other than contraception)? *
Have you recently started taking any new regular prescription medication (other than contraception)?
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Do you have any medical history or problems that may present contraindications to the practice of diving? *
Do you have any medical history or problems that may present contraindications to the practice of diving?
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Action to take:
  • If you answered YES once : You must consult a doctor and obtain a CACI (Medical Certificate of Absence of Contraindication to the practice of underwater activities) in order to be able to practice diving safely.
  • If you answered NO to all the questions: You can practice diving by presenting the declaration of fitness for scuba diving below:
I certify the accuracy of the data entered, and declare that after completing the self-questionnaire, I am fit to practice scuba diving. *
I certify the accuracy of the data entered, and declare that after completing the self-questionnaire, I am fit to practice scuba diving.
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Parent or guardian where applicable, I certify the accuracy of the data entered for my child, and declare after having completed the self-questionnaire, that he/she is fit to practice scuba diving.
Parent or guardian where applicable, I certify the accuracy of the data entered for my child, and declare after having completed the self-questionnaire, that he/she is fit to practice scuba diving.
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Image rights authorization (we may film you underwater) *
Image rights authorization (we may film you underwater)
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