Form Cg-719k - Mershant Mariner Physical Examination Report Page 3

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Department of Transportation
OMB-2115-0514
Merchant Mariner Physical Examination Report
U.S. Coast Guard
Page 3
CG-719K (Rev 1/02)
Section I – Applicant Information
Name (Last, First, Middle) of Applicant
Date of Birth (Month, Day, Year)
Social Security Number
Section II - Physical Information
Eye Color
Hair Color
Weight
Distinguishing Marks
________lbs
Height
Blood Pressure
Pulse Resting
______ft ______in
Systolic _______ / Diastolic _______
________
Regular
Irregular
Section III - Vision
(if you have corrected vision, BOTH uncorrected & corrected MUST be shown)
UNCORRECTED
CORRECTABLE TO
FIELD OF VISION
Right
20
/
____________
Right
20
/
_____________
Normal
The applicant must have 100
degrees horizontal field of vision
Left
20 /
____________
Left
20
/
_____________
Abnormal
Section IV – Color Vision
Deck Officers/Ratings (masters, mates, pilots, operators, able-seaman) must be tested
PASS
FAIL
using one of the following tests. For all other licenses/ratings, see page 1, note 3.
Pseudoisochromatic Plates
Eldridge - Green Perception Lantern
Divorine - 2nd Edition
Farnsworth Lantern (FALANT)
AOC
Keystone Orthoscope
AOC Revised Edition
Keystone Telebinocular
AOC - HRR
SAMCTT- School of Aviation Medicine
Ishihara 16, 24, 38 Plate Edition
Titmus Optical Vision Test
Williams Lantern
Section V - Hearing
:
NORMAL
IMPAIRED (If impaired, complete Audiometer and Functional Speech Discrimination Test)
Audiometer
500 Hz
1000 Hz
2000 Hz
3000 Hz
(Threshold Value)
Right Ear (Unaided)
Left Ear (Unaided)
Right Ear (Aided)
Left Ear (Aided)
Right Ear (Unaided) ___________%
Left Ear (Unaided) __________%
Functional Speech Discrimination Test at 55 dB
Right Ear (Aided)
___________%
Left Ear (Aided)
__________%
Section VI - Medications
List all current medications, including dosage and possible side effects.
NO PRESCRIPTION
MEDICATIONS
State the condition(s) for which the medication(s) are taken.

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