MEDICAL CERTIFICATE. Date of Birth Sex Nationality ID (Passport/Discharge book) No:
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1 Photo MEDICAL CERTIFICATE Surname Other Names Position applied for Date of Birth Sex Nationality ID (Passport/Discharge book) No: Ship Name I have evaluated the above named examinee according to (national law, regulation or other requirement), and on the basis of the examinee s personal declaration, my clinical examination, and the diagnostic test results obtained, and in consideration of the essential requirements of the position applied for, in my opinion this employee DOES / DOES NOT meet the physical requirement for this job. Restrictions applied: None/ If unfit state reason Visual aid required (specify) Yes/No Informed spares necessary Yes/No Fit for lookout duty Yes/No Expiry date Signed: Authorizing body: (Government/Maritime Administration) Name: Clinic stamp: Date: I acknowledge that I have been advised of the content of the medical examination form. Examinee s signature: A copy of this page should be kept by the examining physician. The original should be given to the seafarer. INTERNET NO: Page 1
2 MEDICAL EXAMINATION REPORT STRICTLY CONFIDENTIAL This examination must be carried out by an authorised physician. The seafarer must meet the minimum standards set down by the authorising body. Reference should also be made to the ILO and UK P & I Club PEME guidelines. Surname Other Names Date of Birth Sex Position/Job Applied For Home Address Usual Medical Practitioner Name/Address Date/result of last medical examination: Date/result of last PEME examination (if any): PRE EMPLOYMENT QUESTIONNAIRE PERSONAL MEDICAL HISTORY To be completed by the examining physician in consultation with the seafarer. Vaccination status (This section is for infor mation only. No vaccinations are required/authorized as part of this exam). Vaccination status (state date of last vaccination/immunity): Diphtheria: Tetanus: Pertussis: Polio: Hepatitis A: Typhoid : Hepatitis B: Yellow Fever: R: Varicella: Advice given regarding vaccinations required: Yes/No To the best of your knowledge, have any of your family ever suffered from any of the following? Heart conditions/angina, Blood pressure problems, Stroke/vascular disease, Mental/nervous, disorder, Diabetes, Tuberculosis, Asthma/eczema, Glaucoma, Epilepsy/fits, Cancer, Anaemia If yes, please give details: Are you taking any non prescription or prescription medications? Please list with dosage, and reason for taking Have you any allergies to medications, or to environmental allergens eg Hay Fever? Do you smoke? Yes/No Number of cigarettes per day Do you drink alcohol? Yes/No Number of units per week Do you feel healthy and fit to perform the duties of your designated position/occupation? Yes/No Have you ever been declared unfit for sea duty, or had your medical certificate restricted or revoked? Yes/No INTERNET NO: Page 2
3 Have you ever had any medical conditions affecting the systems below? Y N If yes, give details: Eye or vision problem: eg glaucoma, eye injury, glasses/ contact lenses Dental problems Ear/nose/throat problems: eg Ear Infections, Hearing Problems, Sinus Trouble, Recurrent Nose Bleeding, Heart problems: Rheumatic Fever, abnormal heart beat, Chest Pain, Heart Attack, Heart surgery Vascular disease: High blood pressure, Varicose veins, Poor Circulation Chest problems: Shortness of Breath, Coughing up Blood, Asthma/bronchitis, Wheezing, Pneumonia, Pleurisy, TB Endocrine or hormone disorders: Diabetes or blood sugar problems, Thyroid problem Malignant Diseases: Cancer or Tumour, Blood disorders Kidney problems: Urinary Infections, Blood in Urine, Kidney Stones Genital disorders: Sexually Transmitted Disease Males: Prostate Disease, Testicular lumps or swellings, Varicocele Females: Gynae problems, abnormal smears, painful periods, pregnancy problems, Breast lumps. Date of last menstrual period: (exclude Pregnancy) Skin problems: dermatitis, rashes, eczema, psoriasis Infectious/contagious diseases: Malaria or other tropical diseases, HIV / AIDS Digestive disorder: Frequent Indigestion, Gastric/Duodenal Ulcer, Abdominal Pain Diarrhoea, Constipation, Bleeding from gut, Jaundice, hepatitis or Liver Complaints, Hernia, Haemorrhoids/piles Neurological problems: Epilepsy, seizures or Blackouts, Dizziness/fainting, Loss of consciousness, Frequent Severe headaches or Migraines, Muscular Weakness or Paralysis, Tingling or Numbness, Balance problems, Stroke, Head Injury or Concussion, loss of memory. Psychiatric problems: Anxiety, Depression, Sleep problems, Nervous Breakdown, suicide attempt Restricted mobility: Back problems, Sciatica, Fractures, Dislocations, Severe Sprain, Arthritis, Rheumatism, Joint pain. Apart from conditions as above, have you had any other Operations or surgery, Serious accidents or injuries, Medical problems, diseases or illnesses, visits to health care professionals or hospital admissions? Yes/No I certify that the above medical information is true and any false information provided will be grounds for immediate dismissal. Any failure to disclose any pre existing medical condition will be grounds to exclude claims for any illness/injury and other benefits to which I might otherwise be entitled. The details of my medical examination may be released to my own doctor and also the results may be communicated to the personnel department of the company/uk Club for whom this examination is carried out. I hereby authorize the release of all my previous medical records from any health professionals, health institutions and public authorities to Dr.. Signed: (Applicant) Witness: Date: INTERNET NO: M Page 3
4 Physical Examination Height (cm) Weight (kg) BMI (kg/m 2 ) Rate Rhythm Systolic Diastolic Pulse Blood Pressure Vision Distance (Snellen chart) Unaided R 6/ L 6/ Both 6/ Aided R 6/ L 6/ Both 6/ Near (Sloan letters) Unaided R N L N Both N Aided R N L N Both N Audiogram right ear Khz 500 1,000 2,000 4,000 6,000 8,000 db left ear Khz 500 1,000 2,000 4,000 6,000 8,000 db Ishihara Normal/Abnormal Visual fields Normal/Abnormal Whisper test R cm L cm Lung Function PEFR FEV1 FVC Urinalysis (+/ ) Glucose Protein Blood Systems examination Normal/Abnormal (give detail) General appearance Eyes, pupils Vascular (inc. pedal pulses) Varicose veins Normal/Abnormal (give detail) External Ocular Movements Opthalmoscopy Ear, inc Tympanic Membrane Nose Abdomen, inc Hernial orifices Genito urinary(not Pelvic Exam) Anus, (Not Rectal Exam) Musculo skeletal Throat Mouth, Teeth, speech Breast examination Spine Cervical, thoracic and lumbar CNS inc general neuro exam Lymphatic system Chest and lungs Skin Heart Mental capacity INTERNET NO: Page 4
5 Test Results See guidelines for requirements for each test (** optional) Chest X Ray Electrocardiogram (only for individuals aged 50 and above, unless otherwise requested). Full Blood Count Urea, electrolytes, Creatinine, Glucose, LFTs Hepatitis A Hepatitis B HBsAg, if positive other markers to establish infectivity Hepatitis C anti HCV Syphilis serology VDRL/RPR HIV Drug & Alcohol screening ** Food handlers screening** Other: State whether applicable, Positive/Negative, Normal, or if abnormal give details Other: Consent for HIV Test (No HIV test may be conducted in the USA or where otherwise prohibited by applicable law) I declare that I am not a citizen or resident of the United States and that I am willing to undergo testing for HIV antibodies (AIDS test) and consent to the taking of a sample for this purpose. If the test proves positive, I agree to the results being passed on to my medical practitioner. Signature... Witnessed by... Date... Date... Fit/Temporarily unfit/permanently unfit Name of Doctor: Action required prior to certification, e.g. referral: Review date: Signature of Doctor: Authorising body: Date of examination: Name of examining Clinic/Hospital: Clinic Stamp: The original of pages 2 5 should be kept by the examining physician, and a copy given to the seafarer. INTERNET NO: Page 5
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Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
APPLICATION FOR ALTERATIONS / REINSTATEMENT OF INSURANCE POLICY
EuroLife Ltd 4 Evrou Str., 2003 Strovolos, P.O.Box 21655, 1511 Nicosia Tel: 22124000 Fax: 22341090 APPLICATION FOR ALTERATIONS / REINSTATEMENT OF INSURANCE POLICY PART Á: To be completed in every case
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Caribbean School of Medical Sciences, Jamaica Medical Student Health Services 8 Waterloo Rd, Kingston Jamaica. Dear Prospective Student,
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Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist
GFP GARDENS FAMILY PRACTICE Phone (561) 627-7433 Fax (561) 775-1055 Welcome To Gardens Family Practice! We are happy to have you join our family and would like to give you some general information regarding
GROUP INSURANCE EVIDENCE OF INSURABILITY FORM. SECTION 1: EMPLOYER INFORMATION (to be completed by authorized Plan Administrator):
GROUP INSURANCE EVIDENCE OF INSURABILITY FORM RBC Life Insurance Company 6880 Financial Drive, Tower 1, Eighth Floor Mississauga, Ontario L5N 7Y5 Please answer all applicable questions; all subsequent
Your application to join
Philip Williams Bupa Healthcare Scheme Your application to join Underwritten Thank you for choosing us. Before we can welcome you as a member, please complete this application form as fully as possible.
Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance
Dear Incoming Student:
FOR THE ADVANCEMENT OF SCIENCE AND ART Dear Incoming Student: It is mandatory that you complete and return the enclosed Cooper Union health forms and the New York State required response forms for Meningitis,
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day
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CIGNA GLOBAL HEALTH OPTIONS APPLICATION FORM HELLO We re glad you would like to join us. Please complete this application form and return it to us, either by electronic mail, fax or post. See our contact
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
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THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
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Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges
To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department