Format For Recording Medical Examinations Of Seafarers (Page 4 of 4) in pdf

Format For Recording Medical Examinations Of Seafarers Page 4

Other diagnostic tests and results:

Test:

Result:

Medical practitioner’s comments and assessment of fitness, with reasons for any limitations:

Assessment of fitness for service at sea

On the basis of the examinee’s personal declaration, my clinical examination and the diagnostic

test results recorded above, I declare the examinee medically:

Fit for look-out

Not fit for look-out duty

Deck service

Engine service

Catering service

Other services

Fit

Unfit

Without restrictions

With restrictions

Visual aid required

Describe restrictions (e.g. specific positions, type of ship, trade area)

Medical certificate’s date of expiration (day/month/year):

Date of medical certificate issued (day/month/year):

Number of medical certificate:

Name of medical practitioner (typed or printed):

License number of medical practitioner:

Address of medical practitioner:

Authorized by: Panama Maritime Authority

Signature of medical practitioner: _________________________________

Seal:

F-ALM-011

Rev. 03

Page 4 de 4

Date: 13/03/2013.

Format For Recording Medical Examinations Of Seafarers Page 4