Medical Questionnaire
Miss - Mrs – Mr ..................................................
Date of birth: ..........................
To do this activity, you should not have any health problems that might be aggravated or contribute to an accident. In
accordance with federal regulations (conforming to the French law of 28 April 2000 of the Ministry of Youth and Sports), you are
asked to carefully complete the questionnaire. If you answer “YES to any of these questions, you should be examined by a
doctor for assessment of potential risks before being granted access to this attraction.
This activity is not recommended during pregnancy. We encourage you to treat your dental cavities.
Excessive alcohol consumption and the use of illegal drugs are incompatible with this activity.
Please tick the appropriate box:
1. Have you been a victim of pulmonary overinflation or decompression sickness?
Yes □
No □
2. Do you have a disability?
Yes □
No □
3. Have you had or do you have:
Heart or circulatory problems?
Yes □
No □
4. In particular: high blood pressure (even treated)?
Yes □
No □
5. Repeated fainting spells?
Yes □
No □
6. Chronic respiratory problems?
Yes □
No □
7. Asthma?
Yes □
No □
8. A pneumothorax, chest trauma?
Yes □
No □
9. Problems of the ear, nose and throat requiring special medical care?
Yes □
No □
10. Poor hearing, perforated eardrum?
Yes □
No □
11. A chronic sinus or ear infection?
Yes □
No □
12. Dizziness or repeated balance problems?
Yes □
No □
13. Ear pain in water, on an airplane or at high altitude?
Yes □
No □
14. Mental disorders?
Yes □
No □
15. Are you monitored for depression?
Yes □
No □
16. Have you had or do you have: neurological problems?
Yes □
No □
17. Epileptic seizures, treated or not?
Yes □
No □
18. Tetany seizures or hyperventilation?
Yes □
No □
19. Head injury with coma?
Yes □
No □
20. A metabolic disorder?
Yes □
No □
21. Diabetes treated or not?
Yes □
No □
22. An endocrine disorder?
Yes □
No □
23. A tumour?
Yes □
No □
24. Hiatal hernia or acid reflux disease?
Yes □
No □
25. A seeing disorder: severe short-sightedness, corneal disorders, retinal problems?
Yes □
No □
26. Chronic skin conditions?
Yes □
No □
27. Are you taking heart or blood pressure medication, blood thinners or any other medication related to psychiatric or
neurological conditions?
Yes □
No □
28. Have you ever had surgery or endoscopic surgery?
- on the heart or thorax?
Yes □
No □
- on the stomach?
Yes □
No □
- on the ears or sinuses
Yes □
No □
- on the brain
Yes □
No □
- on the eyes (including laser surgery)?
Yes □
No □
29. Have you experienced any leave of absence in the past month due to illness or an accident?
Yes □
No □
30. Do you need long-term medical care, surgery, endoscopic surgery or hospitalisation in the next 6 months?
Yes □
No □
I declare to have read and understood the questions above and certify that my answers are correct.
I am fully aware that any misrepresentation involves my own personal liability and not that of Marineland.
Signed on ...............
in ...........................
Signature:
(or signature of parent or guardian if a minor)
Warning
Reminder: You are liable in the event of any false declaration, and your dated signature certifies the truthfulness of your state of
health.