Nom:                                                                                                                                                    Prénom:                                                                                                                                               

Age:                                                              Sexe:                                                                               Profession:                                                                                                                                           

Etes-vous:    gaucher q   ou          Droitier      q

Depuis quand pratiquez-vous la plongée sous-marine?                                                                                                                                        

A quand remonte votre dernière plongée?                                                                                                                                              

En moyenne plongez-vous[1]                                                         q >1 fois par semaine?

                                                                                                        q 1 fois par semaine?

                                                                                                        q 1 fois tous les quinze jours?

                                                                                                        q 1 fois par mois?

                                                                                                        q En vacances seulement?

Nombre approximatif de plongées éffectuées à ce jour:                                                                                                                                                     

Nombre approximatif d'heures passées en immersion:                                                                                                                                           

Pratiquez-vous régulièrement une (des) activité(s) suivantes:

                                                                                                        q Apnée

                                                                                                        q Natation

                                                                                                        q Natation synchronisée

                                                                                                        q Water-polo

Audiograme

Lieu & date                                                        Signature                                                                        

[1]  Cochez la case correspondante.