DAN Medical Research
Project Dive Exploration : 48-Hour Report Form

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