CAROTID ARTERY DOPPLER
A Prospective Study of the Risk for Decompression Sickness
in Divers with Right-to-Left Shunts
Diver Initial Evaluation Form
Name of Examiner :
Examiner Number : ______
Study number of Diver (2 digits, preceded by the Examiner Number) : /
Date of Carotid Artery Doppler test :
Result : Positive (bubble sounds heard)
Negative (no bubble sounds heard)
Diver Data :
Sex : M F Age : yrs Date of Birth :
Weight (kg) :
Height (cm) :
Smoking habits (Pack-Years) :
Diving experience : Years : No. of Dives :
Average No. of Dives per year :
The examiner should keep a database with the name, address, telephone, fax, mobile phone numbers as well as e-mail address when available. This database should also contain the Divers' Study Number. These data will serve to send the diver a "study package" and to re-contact the diver at the end of the 5 years study period. An on-line database will be developed in order to allow secure transmission of these data to DAN.
The diver should be blinded to the result of his Carotid Dopler test in order not to influence his diving behaviour. It should be explained to him that, in the current knowledge of science, the risk of decompression sickness is slightly elevated in divers with PFO, but that this risk does not justify a change in diving habits if they already comply with what DAN considers "safe diving". By participating in this study, the diver consents in being kept ignorant of the result, and accepts that DAN will only inform him of the result at the end of the study period or if new and important information should become available.
The diver has been blinded to the result of the test : Yes No
Fax or e-mail this form to: +32 2 264 48 61
CAROTID ARTERY DOPPLER
A Prospective Study of the Risk for Decompression Sickness
in Divers with Right-to-Left Shunts
Diver Initial Database
Name of Diver :
Study number of Diver (2 digits, preceded by the Examiner Number) : /
Address :
Zip code : City : Country :
Phone numbers : Home Mobile
Fax
E-mail address :
Date of Carotis Doppler Test :
The diver has been blinded to the result of the test : Yes No
Other remarks (for investigator use only) :
Enter these data in an Excel or other database and keep a regular backup. Send this database each trimester to so that the divers can be sent a study package and Card by DAN Europe HQ.