Format For Recording Medical Examinations Of Seafarers Page 3

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MEDICAL EXAMINATION
Sight
Use of glasses or contact lenses: Yes/No (if yes, specify which type and for what purpose)
Visual acuity
Visual fields
Unaides
Aided
Normal
Defective
Right
Left
Binocular
Right
Left
Binocular
Right eye
eye
eye
eye
eye
Distant
Left
eye
Color vision
Not tested
Normal
Doubtful
Defective
Hearing
Pure tone and audio metry (threshold values in dB)
Speech and whisper test (metres)
Normal
Whisper
500 Hz
1,000 Hz
2,000 Hz
3,000 Hz
Right ear
Right ear
Left ear
Left ear
Clinical data
Height:
(cm)
Weight:
(kg)
Pulse rate:
(/minute)
Rhythm:
Blood pressure:
Systolic :
( mmHg)
Diastolic :
( mmHg)
Urinalysis:
Glucose:
Protein:
Blood:
Normal
Abnormal
Normal
Abnormal
Head
Skin
Sinuses, nose, throat
Varicose venis
Mouth/teeth
Vascular (inc. Pedal pulses)
Ears (general)
Abdomen and viscera
Tympanic membrane
Hernias
Eyes
Anus (not rectal exam.)
Ophthalmoscopy
G-U system
Pupils
Upper and lower extremities
Eye movement
Spine (C/S, T/S and L/S)
Lungs and chest
Neurologic (full brief)
Breast examination
Psychiatric
Heart
General appearance
Chest X-ray
Not performed
Performed (day /month /year)
/
/
Results:
F-ALM-011
Rev. 03
Page 3 de 4
Date: 13/03/2013.

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