FORMAT FOR RECORDING MEDICAL EXAMINATIOS

OF SEAFARERS
Name (last, first, middle):
Date of birth (day/month/year):

Sex:

Male

Female

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

EXAMINEES 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 joint problems
Amputation
Fractures/dislocation

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

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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):

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):

Witnessed by: (Signature): ___________________________________________________________

Name: (Typed or printed):
Date and contact details for previous medical examination (if known):

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Date: 13/03/2013.

MEDICAL EXAMINATION
Sight
Use of glasses or contact 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:

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Date: 13/03/2013.

Other diagnostic tests and results:

Test:

Result:

Medical practitioners comments and assessment of fitness, with reasons for any limitations:

Assessment of fitness for service at sea

On the basis of the examinees 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 certificates 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:

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Date: 13/03/2013.