Cg-719k - Merchant Marine Physical Examination Report Page 4
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1
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4Department of Transportation
OMB-2115-0514
U.S. Coast Guard
Merchant Mariner Physical Examination Report
Page 4
CG-719K (Rev 1/02)
Section VII – Certification of Physical Impairment or Medical Conditions
• Date of diagnosis
• Identify the condition
Does the applicant have or ever suffered from any of the
If YES:
following?
• Any limitations
• Prognosis
If YES, PROVIDE TEST RESULTS, AS INDICATED.
• Is condition controlled
Remarks (Please Print)
Yes
No
1. Circulatory System
a. Heart disease (Stress Test within the past year)
b. Hypertension (Recent BP reading)
c. Chronic renal failure
d. Cardiac surgery (Stress Test within the past year)
e. Blood disorder/vascular disease
2. Digestive System
a. Severe digestive disorder
3. Endocrine System
a. Thyroid dysfunction (TSH level within the past year)
b. Diabetes (State effects on vision & HgbAlc w/in 30 days)
4. Infectious
a. Communicable disease
b. Hepatitis A, B or C
c. HIV
d. Tuberculosis
5. Mental System
a. Psychiatric disorder
b. Depression
c. Attempted suicide
d. Alcohol abuse
e. Drug abuse
f. Loss of memory
6. Musculoskeletal System
a. Amputations
b. Impaired range of motion
c. Impaired balance/coordination
7. Nervous System
a. Epilepsy/seizure
b. Dizziness/unconsciousness
c. Paralysis
8. Respiratory System
a. Asthma (PFT results within the past year)
b. Lung disease (PFT results within the past year)
9. Other
a. Debilitating allergies
b. Other eye disease (Corrected/Uncorrected Visual acuity)
c. Glaucoma (Pressure test results within the past year)
d. Recent or repetitive surgery
e. Sleepwalking
f. Severe speech impediment
g. Other illness or disability not listed
Considering the findings in this examination, and noting the physical demands that may be placed
Needing
Not
Competent
upon the applicant, I consider the applicant
(please check one)
further
competent
review
Name of Physician/Physician Assistant/Nurse Practitioner
License Number
Telephone Number
Office Address, City, State, Zip
Signature of Physician/Physician Assistant/Nurse Practitioner
Date
I certify that all information provided by me is complete and true to the best of my knowledge
X
Date
Signature of Applicant
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