Medical Examination Report Page 2
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4Have you now, or have you previously had any of the following:
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Lumbago, sciatica or other back trouble
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Any form of arthritis or stiff joints
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Anxiety or depression
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Slipped discs or back or neck pain
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Migraine or persistent headaches
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Joint injuries
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Epillepsy or fits
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Injury of the neck or back
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Poliomyelitis or other paralysis
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Repetitive Strain Injury, tennis elbow, tendonitis
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Attack of unconsciousness or weakness,
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Broken bones
Yes
No
dizziness or turns
Yes
No
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Gout
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High blood pressure
•
Discharge from ears or perforated eardrum
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Disease of the heart, arteries or blood vessels
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Ringing in the ears or disturbances of balance
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Operation on the heart
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Deafness
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Anaemia or any other disease of the blood
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Nasal or sinus trouble
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Swelling of the ankles
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Persistent husky voice or frequent sore throat
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Palpitations
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Goitre or Thyroid disease
Yes
No
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Varicose veins or abnormal bleeding
Yes
No
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Rheumatic fever
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Any form of cancer or unexplained lumps
Yes
No
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Disease of the liver (including jaundice or hepatitis)
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Diabetes
Yes
No
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Disease or ulcer of the stomach or duodenum
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Recurrent abdominal pain/persistent indigestion
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Dermatitis/eczema/skin eruptions
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Appendicitis
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Allergy conditions including hay fever
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Gallbladder disease
Yes
No
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Any abnormality of the immune system
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Disease of the bowels
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Haemorrhoids (piles)
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Any allergic reaction to any serum, drug or medicine
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Hernia (rupture)
(including anaesthetic agents) and vaccines
Yes
No
Yes
No
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Recent change in weight
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Any diseases such as malaria, typhoid,
Yes
No
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Asthma
amoebiasis, giardia etc
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Bronchitis or emphysema
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Tuberculosis
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Severe tooth or gum trouble
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Persistent breathlessness
Yes
No
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Impacted wisdom teeth
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Persistent cough
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Collapsed lung
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Any obstetric or gynaecological problems
Yes
No
Yes
No
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Other lung disease/abnormal x-ray
Yes
No
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Are you pregnant?
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Infection of bladder
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Kidney disease or kidney stone
Please give details of any complaint, illness or injury not
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Difficulty in passing urine
previously mentioned
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Any abnormality of the urine
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Sexually transmitted disease
Yes
No
The following should be signed in the presence of the examining medical officer
WARNING: Giving false or misleading information is a serious criminal offence and may lead to prosecution
Are you aware of ANY circumstances regarding your health which may interfere with
Yes
No
the satisfactory discharge of the duties of your designated position/occupation?
If yes, give details
Declaration
I hereby declare that, to the best of my knowledge my personal statements are true and correct
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Applicant’s signature ................................................................. Date ........./....... /...........
Authority to divulge medical information
If, as a result of this or subsequent examinations for the purposes of assessing my medical fitness for duty at sea, the examining Medical
Inspector requires relevant medical details from my treating medical advisor(s), permission is hereby granted to obtain information from:
Dr ......................................................................... Address & phone ......................................................................................................
(Current General Practitioner)
Dr ......................................................................... Address & phone ......................................................................................................
Dr ......................................................................... Address & phone ......................................................................................................
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Applicant’s signature ................................................................. Date ........./....... /...........
AMSA 232 (6/16) 2 of 4
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