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INTERNATIONAL LABOUR ORGANIZATION |
Sectoral Activities Programme |
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INTERNATIONAL LABOUR ORGANIZATION |
Sectoral Activities Programme |
See text links
below.
ILO/WHO/D.2/1997
Name (last, first, middle): |
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Date of birth (day/month/year): |
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Sex: |
male |
female |
Home address: |
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Passport No./Discharge Book No.: |
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Type of ship (container, tanker, passenger, fishing): |
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Trade area (e.g., coastal, tropical, worldwide): |
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Examinee's personal declaration
(Assistance should be offered by medical staff)
Have you ever had any of the following conditions
Condition |
Yes |
No |
Condition |
Yes |
No |
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1. |
Eye/vision problem |
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18. |
Sleep problems |
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2. |
High blood pressure |
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19. |
Do you smoke? |
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3. |
Heart/vascular disease |
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20. |
Operation/surgery |
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4. |
Heart surgery |
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21. |
Epilepsy/seizures |
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5. |
Varicose veins |
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22. |
Dizziness/fainting |
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6. |
Asthma/bronchitis |
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23. |
Loss of consciousness |
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7. |
Blood disorder |
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24. |
Psychiatric problems |
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8. |
Diabetes |
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25. |
Depression |
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9. |
Thyroid problem |
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26. |
Attempted suicide |
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10. |
Digestive disorder |
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27. |
Loss of memory |
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11. |
Kidney problem |
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28. |
Balance problem |
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12. |
Skin problem |
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29. |
Severe headaches |
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13. |
Allergies |
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30. |
Ear/nose/throat problems |
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14. |
Infectious/contagious diseases |
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31. |
Restricted mobility |
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15. |
Hernia |
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32. |
Back problems |
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16. |
Genital disorders |
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33. |
Amputation |
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17. |
Pregnancy |
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34. |
Fractures/dislocations |
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If any of the above questions were answered "yes", please give details.
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Additional questions
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Yes |
No |
35. |
Have you ever been signed off as sick or repatriated from a ship? |
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36. |
Have you ever been hospitalized? |
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37. |
Have you ever been declared unfit for sea duty? |
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38. |
Has your medical certificate ever been restricted or revoked? |
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39. |
Are you aware that you have any medical problems, diseases or illnesses? |
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40. |
Do you feel healthy and fit to perform the duties of your designated position/occupation? |
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41. |
Are you allergic to any medications? |
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Comments:
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42. Are you taking any non-prescription or prescription medications? |
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If yes, please list the medications taken and the
purpose(s) and dosage(s).
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I hereby certify that the personal declaration above is a true statement to
the best of my knowledge.
Signature of examinee: ________________________________ Date (day/month/year): _____/_____ /________
Witnessed by: (Signature) _______________________ Name: (Typed or printed________________________
I hereby authorize the release of all my previous medical records from any
health professionals, health institutions and public authorities to Dr. ______________________(the
approved medical examiner).
Signature of examinee: ________________________________ Date (day/month/year): _____/_____ /________
Witnessed by: (Signature) _______________________ Name: (Typed or printed________________________
Medical examination
Pre-sea |
Periodic |
Other |
Sight
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Colour vision: Not tested Normal
Doubtful Defective
Hearing
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Pure tone and audio metry (threshold values in dB) |
Speech and whisper test (metres) |
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500 Hz |
4,000 Hz |
2,000 Hz |
3,000 Hz |
4,000 Hz |
6,000 Hz |
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Normal |
Whisper |
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Right ear |
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Right ear |
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Left ear |
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Left ear |
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Height: _______________(cm) Weight: ______________________(kg)
Pulse rate: _________(/(minute) Rhythm: ___________________________________
Blood pressure: Systolic: ______________(mm Hg) Diastolic: ____________________(mm Hg)
Urinalysis: Glucose:
________________ Protein:
________________________
Normal |
Abnormal |
Normal |
Abnormal |
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Head |
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Varicose veins |
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Sinuses, nose, throat |
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Vascular (inc. pedal pulses) |
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Mouth/teeth |
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Abdomen and viscera |
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Ears (general) |
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Hernia |
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Tympanic membrane |
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Anus (not rectal exam.) |
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Eyes |
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G-U system |
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Opthalmoscopy |
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Upper and lower extremities |
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Pupils |
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Spine (C/S, T/S and L/S) |
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Eye movement |
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Neurologic (full brief) |
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Lungs and chest |
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Psychiatric |
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Breast examination |
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General appearance |
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Heart |
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Skin |
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Chest X-ray: Not performed Performed on (day/month/year): ______/_____/______
Results: ______________________________________________________________________________
Other diagnostic test(s) and result(s):
Test |
Result |
Medical examiner's comments:
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Vaccination status recorded: |
Yes |
No |
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 duty |
Not fit for look-out duty |
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Deck service |
Engine service |
Catering service |
Other services |
Fit |
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Unfit |
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Without restrictions With restrictions
Describe restrictions (e.g., specific position, type of ship, trade area)
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Action taken by medical examiner (e.g., referral):
Place of examination: __________________ Date of examination (day/month/year):________ /_______ /______
Medical certificate's date of expiration (day/month/year):________ /________ /_______
Official stamp (also print name of medical examiner if not legible):
Signature of medical examiner: ___________________________
Authorized by: _______________________________________ (competent authority)
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