Medical Examinations Form Panama 4h1n41

FORMAT FOR RECORDING MEDICAL EXAMINATIOS OF SEAFARERS Name (last, first, middle): Date of birth (day/month/year):

/

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Sex:

Male

Female

Home address: port No./discharge book No: Department: (deck/engine/radio/food handling/other): Routine and emergency duties: Type of ship (container, tanker, enger, fishing): Trade area (e.g., coastal, tropical, worldwide):

EXAMINEE´S PERSONAL DECLARATION (ASSISTANCE SHOULD BE OFFERED BY MEDICAL STAFF) Have you ever had any of the following conditions?

Condition

YES

NO

YES

Condition

1.

Eye / vision problem

19. Do you smoke,use alcohol or drugs?

2.

High blood pressure

20. Operation/surgery

3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Heart/vascular disease Heart surgery Varicose veins/piles Asthma/bronchitis Blood disorder Diabetes Thyroid problems Digestive disorder Kidney problems Skin problems

21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

13. 14. 15. 16. 17. 18.

Allergies Infectious/contagius diseases Hernia Genital disorders Pregnancy Sleep problem

31. 32. 33. 34.

NO

Epilepsy/ seizures Dizziness/fainting Loss of consciousness Psychiatric problems Loss of consciousness Attempted suicide Loss of memory Balance problems Severe headaches Ear (hearing/ tinnitus) nose/throat problems Restricted mobility Back or t problems Amputation Fractures/dislocation

If any of the above questions were answered “yes”, please give details

F-ALM-011 Rev. 03 Page 1 de 4 Date: 13/03/2013.

Additional questions 35. 36. 37. 38. 39. 40.

YES

NO

Have you ever been signed off as sick or repatriated from a ship? Have you ever been hospitalized? Have you ever been declared unfit for sea duty? Has your medical certificate ever been restricted or revoked? Are you aware that you have any medical problems, diseases or illness? Do you feel healthy and fit to perform the duties of your designed position/occupation?

41. Are you allergic to any medications? Comments:

SI

NO

42. Are you taking any non-prescription or prescription medications? If yes, please list the medications taken and the purpose(s) and dosage(s).

I hereby certify that the personal declaration above is a true statement to the best of my knowledge. Signature of examinee: _______________________________________________________________ Date (day/month/year):

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/

Witnessed by: Name: (typed or printed): I hereby authorize the release of all my previous medical records from any health professionals, health, institutions and public authorities to Dr. (the approved medical practitioner). Signature of examinee: _______________________________________________________________ Date (day/month/year):

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Witnessed by: (Signature): ___________________________________________________________ Name: (Typed or printed): Date and details for previous medical examination (if known):

F-ALM-011 Rev. 03 Page 2 de 4 Date: 13/03/2013.

MEDICAL EXAMINATION Sight Use of glasses or lenses: Yes/No (if yes, specify which type and for what purpose) Visual acuity

Visual fields

Unaides Right eye

Left eye

Aided Binocular

Right eye

Left eye

Normal Binocular

Defective

Right eye

Distant

Left eye

Color vision

Not tested

Normal

Doubtful

Defective

Hearing Pure tone and audio metry (threshold values in dB)

500 Hz

1,000 Hz

2,000 Hz

Speech and whisper test (metres) Normal

3,000 Hz

Right ear

Right ear

Left ear

Left ear

Whisper

Clinical data Height:

(cm)

Pulse rate:

(/minute)

Blood pressure: Urinalysis:

Weight:

Glucose:

Rhythm:

Systolic : Protein:

Normal Head Sinuses, nose, throat Mouth/teeth Ears (general) Tympanic membrane Eyes Ophthalmoscopy Pupils Eye movement Lungs and chest Breast examination Heart Chest X-ray

(kg)

( mmHg)

Diastolic :

( mmHg)

Blood:

Abnormal

Not performed

Normal Skin Varicose venis Vascular (inc. Pedal pulses) Abdomen and viscera Hernias Anus (not rectal exam.) G-U system Upper and lower extremities Spine (C/S, T/S and L/S) Neurologic (full brief) Psychiatric General appearance Performed (day /month /year)

/

Abnormal

/

Results:

F-ALM-011 Rev. 03 Page 3 de 4 Date: 13/03/2013.

Other diagnostic tests and results: Test:

Result:

Medical practitioner’s comments and assessment of fitness, with reasons for any limitations:

Assessment of fitness for service at sea On the basis of the examinee’s personal declaration, my clinical examination and the diagnostic test results recorded above, I declare the examinee medically: Fit for look-out

Not fit for look-out duty

Deck service

Engine service

Catering service

Other services

Fit Unfit Without restrictions

With restrictions

Visual aid required

Si

No

Describe restrictions (e.g. specific positions, type of ship, trade area)

Medical certificate’s date of expiration (day/month/year): Date of medical certificate issued (day/month/year):

/ /

/ /

. .

Number of medical certificate: Name of medical practitioner (typed or printed): License number of medical practitioner: Address of medical practitioner: Authorized by: Panama Maritime Authority Signature of medical practitioner: _________________________________ Seal:

F-ALM-011 Rev. 03 Page 4 de 4 Date: 13/03/2013.