Please contact us via WECHAT or EMAIL asap after you have completed the registration form
￥1200 per person deposit is required to secure your spot*
Payment can be made either via WECHAT PAY or PAYPAL at
yiyang@apneaera.com
If you have any problems with registering, do not hesitate to contact Apnea Era via yiyang@apneaera.com or wechat us at apnea.era
健康状况声明 Medical Statement
在点击提交前，请仔细阅读如下与内容。这些内容是关于您能否安全参加自由潜水活动的健康声明。为了您的安全，您需要具备良好的健康状况才适合参加自由潜水这项目运动。
请点击勾选“是”或“否”。选项如果出现“是”，不一定意味着您不适合参加自由潜水，但需要及时向我们咨询。有些疾病选项如果出现“是”，则需要医生签字与同意，
才可以参加自由潜水活动
Please read the conditions below carefully before you submit. The is a statement in which you
are informed of some of the potential risks associated with freediving. Freediving is a
physically strenuous activity, to freedive safely, you must be in good physical condition.
Please answer each question with YES or NO answer. A YES answer to a question does not
necessarily disqualify you from freediving but may require the approval of a physician before
participation in freediving activity. Please contact us if you have any YES questions.
*怀孕 Pregnant
您目前是否已怀孕？或者认为可能已怀孕？ Do you think you are or might be pregnant?
否 NO是 YES
*神经系统疾病 Neurological Conditions
您是否目前或曾具有相关神经系统疾病，尤其是：癫痫、抽搐、中风、昏迷、晕厥、脑部手术、严重偏头痛、脑血管动脉瘤或服用药物来治疗或预防这些疾病？ History or present condition of seizures, epilepsy, convulsions, strokes, black outs,
brain surgery, severe migraines, aneurysm or taking any medicines to treat or
prevent any of these?
否 NO是 YES
*心血管疾病 Cardiovascular Conditions
您是否目前或曾具有相关心血管系统疾病，包括并不限于：心脏病发作、心脏手术、中风、心血管动脉瘤、高血压、低血压、心绞痛、心律失常或服用药物来治疗或预防这些疾病？ History or present condition of any cardiovascular abnormalities including but not
limited to heart attack, heart surgery, stroke, aneurysm, hypertension, hypotension
, angina, arrhythmia or taking any medicines to treat or prevent any of these?
否 NO是 YES
*肺部与呼吸系统疾病 Pulmonary and respiratory conditions
您是否目前或曾具有相关呼吸系统疾病，包括并不限于：肺功能衰竭、气胸、肺病、肺囊肿、肺气肿、呼吸困难、哮喘、气喘或服用任何药物来治疗或预防这些疾病？
History or present condition of any pulmonary abnormalities including but not limited to
collapsed lungs, pneumothorax, lung disease, lung cysts, emphysema, breathing
difficulties, asthma, wheezing disorders or taking any medicines to treat or prevent any
of these?
否 NO是 YES
*耳部与窦道疾病 Ear/Sinus
您是否目前或曾具有相关耳部或窦道疾病，包括并不限于：耳膜永久性穿孔、耳膜破裂、听力丧失、窦腔囊肿、窦道感染、无法平衡耳压、身体平衡能力问题或服用任何药物来治疗或预防
这些疾病？
History or present condition of any ear or sinus abnormalities including but not limited
to permanent holes in the eardrums, ruptured eardrum, hearing loss, cysts in
sinus cavity, persistent sinus infections, inability to equalize ears, problems with
balance or taking any medicines to treat or prevent any of these?
否 NO是 YES
*糖尿病或低血糖 Diabetes/Hypoglycemia
您是否目前或曾具有糖尿病或者低血糖，或服用任何药物来治疗或预防这些疾病？
History or present condition of diabetes or hypoglycemia or taking any medicines to
treat or prevent any of these?
否 NO是 YES
*眼部方面的疾病 Eye conditions
您是否目前或曾具有眼部疾病，包括并不限于：眼部手术、眼压过高、视网膜剥离？
History or present condition of eye surgery, ocular hypertension or retinal detachment？
否 NO是 YES
*药物治疗 Medications
你是否在服用处方药或非处方药？
Any medication taken on a regular basis either over-the-counter or prescribed by a
physician?
否 NO是 YES
*精神或情绪疾病 Mental and Mood Conditions
您是否目前或曾具有精神疾病或情绪障碍，包括但不限于：精神分裂症，偏执狂，歇斯底里症。
History or present condition of mental illness or mood disorder including, but not
limitedto schizophrenia, paranoid disorder, bouts of hysteria.
否 NO是 YES
*一般身体或心理问题 General Medical Conditions
您目前是否具有身体或心理问题，可能影响您在水下环境中的安全或在身体或心理压力下影响您判断的身体或心理状况。
Any physical or emotional condition not mentioned that might affect your safety in an
underwater environment or affect your judgment under times of physical or
emotional stress.
否 NO是 YES
*自由潜水/水肺潜水史 Freediving/Scuba Diving History
你是否曾出现过包括但不限于：潜水事故史、严重缺氧昏迷、减压病、内耳空气减压、逆向阻塞、肺挤压、肺气压伤导致吐出粉红色泡沫或肺出血
Including, but not limited to history of a diving accident, severe blackout,
decompression sickness, decompression of the inner ear of air, reverse block, lung
squeeze,
any lung squeeze producing pink foam, pulmonary bleeding？
否 NO是 YES
*新冠肺炎核酸阳性或健康码非绿码（Covid-19 positive/non-Green Health Code ）
您是否目前或曾出现新冠核酸检测阳性，或目前健康码为非绿码？
History or present COVID-19 tests positive, or present non-Green Health Code？
