MILPERSMAN 1220-100 EXHIBIT 8

DIVER/BUD/S MEDICAL SCREENING QUESTIONNAIRE

NAME/RANK:	SSN:		DOB:
PRESENT COMMAND:	BR OF SERVICE:		DATE:
(CONCEALMENT OF MEDICAL HISTORY WILL BE REPORTED TO HIGHER AUTHORITIES AND MAY RESULT IN PERMANENT DISQUALIFICATION.)
DIVING MEDICAL QUESTIONS			Yes	No
1. Have you ever been found medically disqualified for a dive physical or any other physical at any time?
2. Since your last physical, or in the last 18 months, have you been sick, injured, consulted a physician, used medication (including over-the-counter), or been hospitalized for any reason?
3. Have you ever experienced any middle or inner ear dysfunction including inability to equalize middle ear pressure, inner or middle ear surgery, ringing, dysequilibrium, hearing deficit?
4. Is or has your uncorrected vision ever been worse than 20/20 in either eye?
5. Do you have any difficulty distinguishing colors or seeing at night?
6. Have you ever had any corneal surgery, or manipulation to correct poor vision?
7. Since age 12, have you had asthma or wheezing at any time?
8. Have you ever had a collapsed lung (pneumothorax), experienced pulmonary barotrauma, had a positive PPD, or taken INH in the past 6 months?
9. Do you have any skin condition worsened by tight clothing, moisture, or sun exposure?
10. Do you have any musculoskeletal condition that limits intense exercise, suffered any type of fracture in the last 3 months, or had any bone/joint surgery in the last 6 months?
11. Have you ever been evaluated for, or treated for, any psychiatric problems (including depression, anxiety, personality disorder, etc.)?
12. Have you ever had legal, professional or personal problems due to alcohol use, or been diagnosed with dependence, or had any level of treatment for abuse?
1 3. Have you ever had a migraine or other severe headache?
1 4. Have you ever had seizures, convulsions or sustained a head injury resulting in loss of consciousness, loss of memory, concussion, or skull fracture?
15. Have you ever had brain surgery?
1 6. Do you have any area of altered sensation or strength in your body?
1 7. Have you ever suffered Decompression Sickness or Arterial Gas Embolism?
18. Do you suffer from motion sickness or fear of enclosed spaces?
PATIENT SIGNATURE:		DATE:

DIVER/BUD/S MEDICAL SCREENING QUESTIONNAIRE (Cont'd.)

ANY POSITIVE RESPONSES REQUIRE ELABORATION ON THIS PAGE BY A DIVING MEDICAL OFFICER

NAME/RANK:

SSN:

DOB:

PRESENT COMMAND:

BR OF SERVICE:

DATE:

ADDITIONAL DIVING MEDICAL QUESTIONS
DMO SCREEN (to be filled out by DMO/UMO, HMO or qualified representative)										Yes	No
1 . SF 88, Report of Medical Examination and SF 93, Report of Medical History are complete, correct, for dive/jump duty and within 1 year of application?
2 . Is the physical signed/countersigned by a DMO/UMO or HMO?
3. Every page of member’s health record has been reviewed?
4. Any disqualifying condition has a completed, approved waiver from BUMED (Med-21)?
5. Any non-disqualifying condition that might affect dive training is thoroughly documented?
DIVING MEDICAL OFFICER COMMENTS
QUESTION#	COMMENT					CD/NCD?			WAIVER?
						Yes No			Yes No










DMO SIGNATURE					DMO STAMP
DMO PHONE NUMBER				DMO FAX NUMBER

RECORD SCREENING (to be filled in by medical department)
G6PD results		Sickle cell results						Blood Type

IMMUNIZATION MUST BE COMPLETED AND CURRENT PRIOR TO TRANSFER			Tetanus				Date
			Typhoid				Date
			Yellow Fever				Date
			HAV				Date
			Flu				Date

ADDITIONAL DIVING MEDICAL QUESTIONS (Cont'd.)
DMO SCREEN (to be filled out by DMO/UMO, HMO or qualified representative)

PPD given with diving medical examination. Yes No Date				PPD Converter YES NO
PPD Converters must complete INH Tx prior to transfer to diver training. PPD annual questionnaire required for converters.

Date of last Dive Physical (SF 88/93):
Dental, must be Class I or II. Last examination date:
Pressure Test, date completed:
NAVMED 6150/2, Special Duty Medical Abstract required with signature from DMO/UMO/HMO stating Physically Qualified for Diving Duty.					Completed
					YES		NO

Visual Acuity: (must correct to 20/20; if not, waiver required) · USN Fleet Diver/Basic Diving Officer, USA OOB, EOD: 20/200 or better. Waiver required if greater · Marine Combat Diver: 20/100 better eye, 20/200 worse eye, or better · Diving Medical Officer and SCUBA: + or – 8 Diopters · SEAL Candidate: 20/40 in best eye, 20/70 in worst eye (Waiverable to 20/70,20/100. Waiver must be completed.)

Hearing Standards:	1000 Hz 30 db 2000 Hz 35 db 3000 Hz 45 db 4000 Hz 55 db	If greater, waiver required.
The following labs are complete on SF 88: Serology, CBC with DIFF, Lipid panel HIV, G6PD, Sickle Cell, and Blood Type?						YES		NO
SEAL, EOD, USA OOB, and Underwater Construction Diver require Fasting Blood Sugar and Routine Urine. (Appropriate /corresponding lab chits are in the medical record.)						YES		NO
The following studies are complete on SF 88: CXR, EKG, Audiogram, PPD, and Falant? (Appropriate/corresponding studies, reports are in the medical record.)						YES		NO
MEDICAL SCREENER NAME, RANK/RATE, AND TITLE			PHONE NUMBER:
			FAX NUMBER:
Command's mailing address

NOTE: THE DIVER MEDICAL SCREENING QUESTIONNAIRE AND SF 88/93 MUST BE COMPLETLEY FILLED OUT AND FAXED TO NAVY DIVING AND SALVAGE TRAINING CENTER (NAVDIVSALVTRACEN), MEDICAL DEPARTMENT, PANAMA CITY, FL PRIOR TO APPLICATION TO NAVY PERSONNEL COMMAND (NAVPERSCOM) (PERS-401D OR PERS-407CK). ANY WAIVERS MUST HAVE WRITTEN APPROVAL BY BUREAU OF MEDICINE AND SURGERY (BUMED) (MED-21) AND A COPY FAXED TO NAVDIVSALTRACEN, MEDICAL DEPARTMENT.

TELEPHONE:

DSN 436-5215 COMM (850) 235-5215

MEDICAL FAX:

DSN 436-5993 COMM (850) 235-5993

STUDENT SUPPORT OFFICE FAX:

DSN 436- 5242 COMM (850) 235-5242

NOTE: FOR SEAL CANDIDATES THE MEDICAL SCREENING QUESTIONNAIRE AND SF 88/93 MUST BE COMPLETELY FILLED OUT AND FAXED TO NAVY SPECIAL WARFARE CENTER, BUD/S MEDICAL DEPARTMENT PRIOR TO APPLICATION TO NAVPERSCOM (PERS-401D). ANY WAIVERS MUST HAVE WRITTEN APPROVAL BY BUMED (MED-21) AND A COPY FAXED TO BUD/S MEDICAL DEPARTMENT.

TELEPHONE:

DSN 577-0777 COMM (619) 437-0777

MEDICAL FAX:

DSN 577-5248 COMM (619) 437-5248

PLACE ORIGINAL DIVER MEDICAL SCREENING QUESTIONNAIRE, SF 88/93, AND ANY APPROVED WAIVERS IN MEDICAL RECORD.

NAVDIVSALVTRACEN HOME PAGE:

www.cnet.navy.mil/ndstc/

NAVY SPECIAL WARFARE CENTER BUD/S HOME PAGE:

www.sealchallenge.navy.mil

DIVING STANDARDS:

NAVMED P-117, Manual of the Medical Department, chapter 15, article 15-66, and section III

BUMEDNOTE 6120 of 30 Jul 97 (canc frp: Jul 98):

http://www.navymedicine.med.navy.mil/instructions/external/6120-7-30-97.pdf

MEDICAL WAIVER:

NAVMED P-117, article 15-74

BUMED (MED-21) TELEPHONE:

COMM (202)762-4342