Divers Alert Network

Thank you for participating in DAN's Project Dive Exploration. It is very important that you complete this questionnaire 48 hours after your last dive or altitude exposure. Without this information, your dive profiles cannot be considered for analysis.

Diver's First Name:

Diver's Last Name:

Email:

Start Date of Trip/Event:

End Date of Trip/Event:

Name of Trip/Event:

FRC's Name (if applicable):

FRC's Code or DiverID:

1) Did you make any additional dives within 48 hours after your last observed dive?

Yes No

If yes, please describe the dive(s) below.

Dive Date Max Depth (fsw) Total Time (min)

#1 fsw min

#2 fsw min

#3 fsw min

2) Were you exposed to altitude within 48 hours after diving?

Yes No

If yes, please describe the exposure(s) below.

Hours Minutes

Surface interval before exposure? hrs min

Type of Exposure Altitude Total Length of Exposure

Hours Minutes

Commercial Aircraft 8000 feet hours min

Ground Transportation feet hours min

MedEvac Aircraft feet hours min

Unpressurized Aircraft feet hours min

3) Did you experience any unusual symptoms within 48 hours after your diving or altitude exposure?

Yes No

If yes, please describe below giving as many details as possible (date, time, location, severity, etc.).

4) Were you treated in a hyperbaric chamber after your diving or altitude exposure?

Yes No

If yes, please describe below.

Name of Facility Location # Treatments

Research