AMERICAN CLUB PRE-EMPLOYMENT MEDICAL EXAMINATION FORM

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IMPORTANT: The original of this form is to be kept by the clinic.

Name : Last Name Mailing Address : First Name Middle Name Seafarers Signature

Date of Birth

Blood Group

Place of Birth (City / Country)

Name of Ship Date:

Medical Certificate No. Examination 1. Medical History Questionnaire (attached) 2. Physical Examination 3. Dental Examination 4. Psychological Test 5. Visual Test 6. Color vision 7. Audiometry 8. Chest X-ray 9. EKG / ECG 10. Urinalysis 11. Fecalysis (food service/handlers only) 12. Complete Blood Count

Seafarers Certificate No. Results of the examination Pass Fail 13. Ultrasound examination (presence of gall & kidney stones) 14. Hep B Antigen 15. Hep C Antibodies 16. VDRL 17. HIV Test 18. Stress Test 19. Diabetes 20. Fasting Blood Sugar 21. Glycosylated Haemoglobin (HbA1c) 22. Liver Function Test (SGPT & SGOT) Examination

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Pass

/
Fail

Results of the Examination

23. Alcohol/Drug Test

24 Spirometry

If failed in any above mentioned examinations, please provide reasons with examination number :

The acceptance or failure of the medical tests is based upon the Am erican Club Pre-Em ploym ent M edical Ex am ination-

Acceptance Guidelines.

Name of Medical Clinic: Address of Medical Clinic: Contact Phone: Contact Fax: Name and Degree of Physician: Name of Physicians Licensing: Date of Issue of Physicians License: Date of Examination:

Signature of Physician

Official Seal

Hologram

AMERICAN CLUB MEDICAL HISTORY QUESTIONNAIRE

Name: Address : Seaman Certificate No.: Employer : In Emergency, Notify : Personal Physician or Clinic : Address : Vessel : Relationship :

Hologram Sticker No. Dr.s Initials

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Date of Birth : Phone : Job Title : Ph. :

Seafarers Signature

Physicians Phone : ALLERGIES: _________________________________________________

Date :

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YES NO

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YES NO

Do you have or have received treatment for the following:

Family History Has anyone in your family ever had :

Yes No Diabetes High Blood Pressure Heart Disease Cancer Yes No Mental Illness Epilepsy/Seizure Yes No Diabetes Heart Trouble High Blood Pressure Shortness of Breath Chest Pain Any other major conditions? Chronic Cough Asthma MALES ONLY Yes No Prostate Problems Testicular Lumps Penile Discharge Are you currently under a doctors care? If Yes, for what problem(s)? Physician(s) Name/Address (if different than noted on page 1): History of surgeries/hospitalizations : If yes, give details : Date of last tetanus Vaccination: Other Vaccinations . Mention : / /
(dd/mm/yyyy) / / / /

Jaundice or Hepatitis Dizziness Back Problems Slipped Disc Wrist Problems Fractured Vertebrae Arthritis / Gout Kidney Problems Cancer / Tumor Rash or Skin Problem Hernia / Hydrocele Varicose Veins Drug Problems Mental Breakdown

If Yes, to any of the above, please explain:

If yes, give details :

FEMALES ONLY Yes No Pregnancy Breast Lumps Menstrual Problems

Tuberculosis Rheumatic Fever Frequent Headaches Vision Problems 20/20 Vision Epilepsy Hearing Problems

Yes

No

Yes

No

Date :

Psychological Impairment, Depression or Mental Illness Sexually Transmitted Disease Yes No Do you or did you smoke? How long? Packs per day? Do you use alcoholic beverages? Do you use or take any drugs? How much/often? Mention drugs used below :

Date of last dental cleaning: Date of recent dental work: Are you presently on any medication :

/ /

/ / Yes

(dd/mm/yyyy) (dd/mm/yyyy)

No

If yes, Please list prescription and over the counter medications you take regularly:

Would you say that your health is (please check one): DECLARATION

Excellent

Good

Fair

I, ________________________________________, Seamans Number _______________, Hereby Declare that I have made full disclosure of all of my medical history to the Doctors and staff of this Clinic. I am aware that the information supplied by forms the basis upon which I will be offered employment as a Seafarer. I understand that in the event of any misrepresentation either by statement or omission I will lose the right to benefit from sick pay and / or compensation which would otherwise be due under the Contract of Employment or under any Collective Bargaining Agreement. I Also Hereby consent to my medical records being made available upon demand to my employers and/or the Owners and/or Insurance of the Vessel or their authorized representatives.