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CONFIDENTIAL
Form : Mex
Medical Examination of Seafarers
Report of Medical Examination by an apprpoved Medical Practitioner
| PERSONAL DETAILS |
Previous Medical History
Does the Seafarer have a medical history of one of the following |
| Name |
______________________________________
Surname, First Name and middle initial |
|
Yes |
No |
Amount below, if positive |
| Date of Birth |
(date) |
(month) |
(year) |
Hypertension |
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Eye trouble/glasses/contact lenses |
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| Nationality |
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Male |
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Stomach/bowel disorder |
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Female |
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ENT |
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| Rank/Rating/Occupation |
______________________________________
______________________________________ |
Hearing impaired |
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| Present type of ship and routes |
______________________________________
______________________________________ |
Skin disease |
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Heart condition Rheumatic fever |
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No. of Discharge Book,
Passport, identity card. |
______________________________________
______________________________________ |
Asthama/bronchitis |
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Hay fever/allergies |
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| Office address |
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Enterovirus |
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Nervous/mental illness |
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Jaundice/liver disease |
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Genito/urinary disorders |
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Back injury/pain |
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Hernia |
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Diabetes |
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Infectious/contagious/tropical diseases |
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Malignant diseases |
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Migraine/severe headaches |
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Head injury/concussion |
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Fractures/dislocations |
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Varicose veins/haemorrhoids |
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Female disorders |
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Tobacco use (quantity) |
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Alcohol intake (quantity) |
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Other illness
Operations |
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Medical Examination
Does the seafarer suffer from any other abnormalities? Please
tick correct box and expand as neccessary
|
Yes |
No |
| Teeth |
|
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| ENT |
|
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| Skin |
|
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| Heart |
|
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| Lungs |
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| Nervous System |
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| Varicose Veins |
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| Genito urinary system |
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| Hernia |
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| Any other defects |
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PHYSICAL EXAMINATION
Height __________cm
Weight __________kg.
Pulse rate _____________
Blood pressure syst. _________ diast. (mm Hg)
Notes:
LABORATORY Urine test: Albumin______
Blood Hb ____ RBC______ WBC_______
Sugar ______ Sedimentation
rate: ____________
ECG
Chest X-Ray
HEARING Normal Left ear ______
m
Whispered voice Left ear ______m
Right ear______m
Right ear______ m
Audiogram:
| Left ear |
kHz 500 1000
2000 3000 |
| dB |
|
|
| Right ear |
kHz 500 1000
2000 3000 |
| dB |
EYE TEST
Distant vision
(expresssed in decimals) |
Unaided Left
Right |
Aided Left
Right |
Both Aided
eyes Unaided |
Colour vision
| _________ |
Ishihara plates |
Normal |
|
| Abnormal |
|
| __________ |
Other method (name) |
Normal |
|
| Not tested |
Abnormal |
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RESULTS OF THE MEDICAL EXAMINATION
(tick correct box)
The international fitness for sea service standards
___________ ____________
(have been met)
(not met)
Assessment: FIT FOR DUTY ____________
NOT FIT FOR
DUTY
____________ ____________
_____________
(permanently)
(temporary)
Should be re-examined
in______days/weeks/months
Recommended tests, consultations,
Rehabilitation etc.:
___________________________
(Doctor's official stamp)
___________________________
(Doctor's signature)
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