Applicant's Name: _________________________________

Age: __________________________ Gender: Male / Female

Address: _________________________________________

City: _____________________ State: ______ Zip: ________

Daytime Phone: ___________________________________

Evening Phone: ___________________________________

USC Catalina
Hyperbaric Chamber
P.O. Box 5069, Avalon, CA 90704-5069
(310) 510-4020 - FAX (310) 510-1362

Clearance for Hyperbaric Exposure
Medical History
You must obtain medical clearance prior to participating in hyperbaric exposures, "dry dives," at the Catalina Hyperbaric Chamber. Complete the following history and take it to your "diving doctor." You must bring this form, or an equivalent recent DIVING medical approval, to the chamber with you. Do you now have, or have you ever had (Check all that apply):
O Seizure disorder (except febrile in infancy) O Recent sprain, fracture, or arthritis
O Recent cardiovascular or neurogenic syncope O Meniere's disease
O Obstructive pulmonary disease O Thoracic surgery or penetrating chest wound
O Arterial gas embolism O Heart disease (myocardial infarction or arrhythmia)
O Pulmonary overexpansion accident O Pneumothorax (spontaneous, surgical, or traumatic)
O Pregnancy (currently) O Decompression sickness with neurological deficit
O Asthma O Blood disorder (Sickle cell anemia; chronic anemia; 2,3, DPG deficiency)
O Claustrophobia
To the Physician
I am applying for the opportunity to participate in hyperbaric chamber (air) exposure dives to 60 feet of seawater (fsw) and/or 165 fsw. I understand that this activity will subject me to pressure in the middle ear and sinuses during pressurization and depressureazation of the chamber and request medical clearance to participate in this activity.

Patient's signature: ___________________________________ Date:____________
Examination: A recent inspiratory chest X-ray should be reviewed to rule out structural weakness and disease of the applicant's lungs and chest wall. Indications of medical history (above) or evidence (below) disqualify the applicant for dives in the Catalina Hyperbaric Chamber.
Subplural bullae or blebs Coin lesion
Pneumothorax Upper respiratory infection (middle ear and/or sinuses)
Air-containing cysts Lower respiratory infection
Atelectasis Inability to perform Valsalva (or any auto-inflate maneuver)
Allergic
O I find that this individual is Cleared for Hyperbaric Exposure
O I am Unable to Recommend this individual for Diving 


Date: ____________ Physician's Signature: __________________________________________



Physician's Name (print): _______________________________ Telephone: _______________



Address: ___________________________________________________________________________



City: _____________________________________ State: _________ Zip: __________________