Seafarer'S Medical Examination Report/certificate
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3SEAFARER’S MEDICAL EXAMINATION REPORT/CERTIFICATE
This certificate is issued by authority of the Maritime Administrator and in compliance with the requirements of the Medical Examination (Seafarers) Convention
1946 (ILO No. 73), as amended, STCW Convention, 1978 as amended and the Maritime Labor Convention, 2006.
SURNAME:
GIVEN NAME (S):
NATIONALITY:
ID DOCUMENT NO:
DATE OF BIRTH:
PLACE OF BIRTH:
SEX:
MALE
FEMALE
MONTH
DAY
YEAR
CITY
COUNTRY
EXAMINATION FOR DUTY AS:
MAILING ADDRESS OF APPLICANT:
MASTER
DECK OFFICER
ENGINEERING OFFICER
RADIO OFFICER
RATING
DECLARATION OF APPROVED MEDICAL PRACTIONER:
I
CONFIRM
THAT
IDENTIFICATION
DOCUMENTS
WERE
YES
NO
CHECKED:
MEDICAL EXAMINATION (SEE LAST PAGE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
HEIGHT
WEIGHT
BLOOD PRESSURE
PULSE
RESPIRATION
GENERAL APPEARANCE
VISION:
HEARING
RIGHT EYE
LEFT EYE
RT. EAR
LEFT EAR
WITHOUT
/
GLASSES
WITH GLASSES
/
YELLOW
RED
GREEN
BLUE
CHECK
IF
COLOR
TEST
IS
BOOK
LANTERN
COLOR TEST TYPE:
NORMAL
DATE OF LAST COLOR VISION TEST:
YES
NO
ARE GLASSES OR CONTACT LENSES NECESSARY TO MEET THE REQUIRED VISION STANDARD?
HEAD AND NECK
HEART (CARDIOVASCULAR)
LUNGS
SPEECH
(DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER)
IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?
EXTREMITIES:
UPPER
LOWER
YES
NO
IS APPLICANT VACCINATED IN ACCORDANCE WITH WHO REQUIREMENTS?
IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY
YES
NO
WORKING ABOARD A VESSEL, OR TO RENDER HIM/HER UNFIT FOR SERVICE AT SEA
OR LIKELY TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD?
YES
NO
IS APPLICANT TAKING ANY NON-PRESCRIPTION OR PRESCRIPTION MEDICATIONS?
SIGNATURE OF APPLICANT
DATE
THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN.
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