Name :           

		Address  :       	

		City :           

		State :          

		Zip Code :       

		E-Mail:          

		Day time Phone:  

		Fax:             

		Date of Visit:   

		Dive Dates:	 

		Number of dives: 

		Date of last Dive:  

		Comments:

			Are you a certified diver?   Yes    No

		If so, please indicate level: 

                and agency: 

		Do you now have or have you ever had a history of cardiovascular, lung disease, asthma, diabetes, respiratory,

		or pregnancy OR are you currently taking any prescriptions?