Medical Examination Report Page 4
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4RESPIRATORY
(See Guidelines - page 8)
NEUROLOGICAL / PSYCHIATRIC
(See Guidelines - page 10)
Is there any evidence of organic disease of
Trachea
Midline
Abnormal
Yes
No
the brain, spinal cord or nerves?
Chest expansion
cm
Abnormal
Is there any evidence of mental or nervous
Breath sounds
Normal
Abnormal
disorder including psychoses?
Yes
No
Spirometry
Actual
Predicted
% Predicted
Is there any evidence suggestive of anxiety,
FEV
panic disorder or personality disorder?
Yes
No
1
FVC
MUSCULOSKELETAL
(See Guidelines - page 13)
FEV
/FVC
1
Does the applicant have normal use of the
Spirometry
FEV
< 65% requires further review
1
Yes
No
legs and arms?
FVC
< 70% requires review
FEV
/FVC < 70% requires review
1
Are there any missing limbs or digits?
Yes
No
Chest X-ray report
Normal
Abnormal
Yes
No
Is gait normal?
(Chest X-rays are required
/
/
20
Date ....................................
for pre-sea medicals or if
Are the bones and joints free of any defects?
clinically indicated.)
Yes
No
(Attach report to this form)
Are joint movements in normal range and
If, after examination you are not satisfied with the clinical condition
Yes
No
pain free?
and efficiency of the respiratory system and chest give reasons
Any restriction or pain in movement of spine?
Yes
No
SKIN / LYMPH NODES
(See Guidelines - page 14)
Is there any skin disease, including solar
keratoses, BCCs, eczema etc?
Yes
No
(See Guidelines - page 9)
MOUTH / TEETH
Are there any significant scars, ulcers, or
Is there any disease or abnormality of the
Yes
No
enlarged lymph nodes?
Yes
No
mouth, throat or neck?
Yes
No
Yes
No
Are there any skin grafts?
Are there any defects in teeth?
Yes
No
Is there any disease of the nose or sinuses?
Are there any identifying marks on the skin?
Yes
No
Details of any abnormalities
Period of review
Under 18/over 55 - 1 year
18 to 55 - 2 years
Other*
*If period of review is “other”, state period and reason.
(See Guidelines - page 9)
GASTROINTESTINAL / RENAL
Is there any disease or abnormality of the
abdominal organs?
Yes
No
Medical Inspector’s signature
Date
If yes, give details
ATTACH ALL TEST DOCUMENTS TO THIS REPORT
Is there any hernia present?
Yes
No
• CHEST X-RAY REPORT
Is the liver enlarged?
Yes
No
(for pre-sea medicals or if clinically indicated)
Glucose
Normal
Abnormal
• ECG TRACING
Urine dipstick
results
(for applicants aged 55 years or more and/or if clinically indicated)
Protein
Normal
Abnormal
• ECG REPORT
Blood
Normal
Abnormal
(confirmed automatic machine report, or report by FRACGP or
Other ................................................................
appropriate specialist)
Hepatitis A arrangements
• STRESS ECG
Does the applicant have active immunity to Hepatitis A
(if clinically indicated)
(completed vaccination course or evidence of past infection)?
• AUDIOGRAM REPORT
Yes
No
(if clinically indicated)
If yes, date of last vaccination
/
/
Original copy of this report is to be forwarded by the Medical
or date of Antibody Positive blood test
/
/
Inspector to Sonic HealthPlus Seafarer Admin Team after the
If no, was Hepatitis A vaccination provided on this occasion?
examination is completed.
Yes
No
The Medical Inspector should retain a copy for record purposes for a
If no, please provide reason
period of at least 30 years.
A copy may be given to the applicant for his/her records if
Hepatitis A arrangements apply to applicants who have a position on
requested.
board marked with an * on the front page of this form.
AMSA 232 (6/16) 4 of 4
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