Survey

We are interested in learning about the occurrence of coughing up blood (hemoptysis) during or shortly after free diving. This condition is commonly referred to as “chest squeeze.” We ask that you take a few minutes to complete this questionnaire. The information is strictly for medical research and the information provided will be kept anonymous and confidential.

1. email (optional):
2. age
3. sex
4. free diving experience in years
5. # dives greater than 50 meters
6. # dives between 30 to 50 meters
7. # dives between 15 to 30 meters
8. # dives between 1 to 15 meters

9. Do you have any medical conditions?	yes no
	If so, list the condition(s):
10. Do you have any lung or chest problems?	yes no
	If so, list the condition(s):
11. Do you have any sinus problems?	yes no
	If so, list the condition(s):
12. Have you taken any medications in the past week?	yes no
	If yes, please list medications:

13. Have you ever coughed up blood during or after a breath holding dive?	never once twice over 2X over 5X many times
14. Were you Short of Breath at any time during any episode of bleeding?	yes no
15. How long did the coughing up blood last?	minutes over 1 hour 1 day several days one week over 1 week
16. Did you receive any medical evaluation or treatment for this problem?	yes no
	If yes, medical exam chest x-ray medications other :
17. Do you have any idea where the blood was coming from?	don't know nose or sinus trachea lungs other
18. Approximate depth of dive associated with the bleeding	5-15 meters 15-30 meters 30-50 meters over 50 meters over 75 meters
19. Was this dive close to your personal best?	yes no
20. Depth of dive prior to the chest squeeze	5-15 meters 15-30 meters 30-50 meters over 50 meters over 75 meters
21. Depth of dive 2 dives prior to the chest squeeze	5-15 meters 15-30 meters 30-50 meters over 50 meters over 75 meters
22. Depth of dive 3 dives prior to the chest squeeze	5-15 meters 15-30 meters 30-50 meters over 50 meters over 75 meters
23. Number of dives in the past month	less than 10 10 to 100 over 100
24. Number of dives in the past 24 hours	none less than 10 more than 10
25. Do You Pack?	never yes, but not on this dive normal packing extreme packing
26. Do you normally have contractions?	yes no
27. Did you have contractions with this dive?	yes no
28. Do You Use Negative Pressure Training?	never yes, but not when the bleeding occured yes, on that dive
29. Did you have any problems equalizing during the dive?	yes no
	Please describe:
30. Were you cold during the dive?	yes no
31. Did you shiver?	yes no
32. Did you notice anything unusual for you during this dive?	yes no
	Please describe:

WORLD

FREEDIVING

MEDICAL

ASSOCIATION