Format For Recording Medical Examinations Of Seafarers

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FORMAT FOR RECORDING MEDICAL EXAMINATIOS
OF SEAFARERS
Name (last, first, middle):
Date of birth (day/month/year):
/
/
Sex:
Male
Female
Home address:
Passport No./discharge book No:
Department: (deck/engine/radio/food handling/other):
Routine and emergency duties:
Type of ship (container, tanker, passenger, fishing):
Trade area (e.g., coastal, tropical, worldwide):
EXAMINEE´S PERSONAL DECLARATION (ASSISTANCE SHOULD BE OFFERED BY MEDICAL STAFF)
Have you ever had any of the following conditions?
YES
NO
YES
NO
Condition
Condition
1.
Eye / vision problem
19. Do you smoke,use alcohol or
drugs?
2.
High blood pressure
20. Operation/surgery
3.
Heart/vascular disease
21. Epilepsy/ seizures
4.
Heart surgery
22. Dizziness/fainting
5.
Varicose veins/piles
23. Loss of consciousness
6.
Asthma/bronchitis
24. Psychiatric problems
7.
Blood disorder
25. Loss of consciousness
8.
Diabetes
26. Attempted suicide
9.
Thyroid problems
27. Loss of memory
10. Digestive disorder
28. Balance problems
11. Kidney problems
29. Severe headaches
12. Skin problems
30. Ear (hearing/ tinnitus) nose/throat
problems
13. Allergies
31. Restricted mobility
14. Infectious/contagius diseases
32. Back or joint problems
15. Hernia
33. Amputation
16. Genital disorders
34. Fractures/dislocation
17. Pregnancy
18. Sleep problem
If any of the above questions were answered “yes”, please give details
F-ALM-011
Rev. 03
Page 1 de 4
Date: 13/03/2013.

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