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					                            THE MARITIME INSTITUTE OF BARBADOS INC.

In Confidence

                                     RECORD OF MEDICAL EXAMINATION OF SEAFARERS



1.           Personal Details of Seafarer                                                         4.            Previous Medical History

Surname .......................................................................................   Does the Seafarer have a medical history of one of
                                                                                                  the following? If so, (please tick the box).
Forenames ...................................................................................
                                                                                                            Hypertension                                                                 [   ]
Discharge Book No. ................................................................. Eye trouble squint                                                                                  [   ]
                                        Tick correct box
                                                                                                            Stomach/bowel disorder                                                       [   ]
Title – Mr [ ] Mrs [ ] Miss [ ] Ms [ ]
                                                                                                            ENT                                                                          [   ]
Any other title held .................................................................. Hearing impaired                                                                                 [   ]
                                                                                                            Skin disease/allergies                                                       [   ]
Date of Birth ............................................................................... Heart condition/rheumatic fever                                                            [   ]
                                   Day                     Month                         Year               Asthma/bronchitis                                                            [   ]
                                                                                                            Hay fever/allergies                                                          [   ]
Rank/Rating/Operation ........................................................
                                                                                                            Epilepsy/fits/fainting                                                       [   ]
                                                                                                            Nervous mental illness                                                       [   ]
2.             Personal Details of Seafarer                                                                 Jaundice/liver disease/piles                                                 [   ]
                                                                                                            Urinary disorders                                                            [   ]
Name .............................................................................................. Back Injury/pain                                                                     [   ]
                                                                                                            Hernia                                                                       [   ]
Address ......................................................................................... Diabetes                                                                               [   ]
                                                                                                            Female disorders                                                             [   ]
...........................................................................................................
                                                                                                            Infectious/contagious/tropical diseases                                      [   ]
                                                                                                            Malignant diseases                                                           [   ]
3.             Family Medical History                                                                       Migraine/severe headaches                                                    [   ]
                                                                                                            Head injury/concussion                                                       [   ]
Has any member of the seafarer’s family ever                                                                Abnormal weight change                                                       [   ]
suffered from:                                                                                              Sexually transmitted diseases                                                [   ]
                                                                                                            AIDS                                                                         [   ]
                               Please tick correct box
                                       Yes         No
Hypertension                           [ ]         [ ]                                            Tobacco intake (quantity) ....................................................
Heart Condition                        [ ]         [ ]
                                                                                                  Alcohol intake (quantity) .....................................................
Tuberculosis                           [ ]         [ ]
Asthma                                 [ ]         [ ]                                            Other illnesses/operations ..................................................
Diabetes                               [ ]         [ ]
Mental Disorder                        [ ]         [ ]                                            Is the seafarer now receiving any treatment?

                                                                                                  ...........................................................................................................




                                                                                                  I certify that this is a true and correct statement.



                                                                                                  Signature of Seaman ...............................................................
5.           Medical Examination

Does the Seafarer suffer from any of the following abnormalities?
Please tick correct box and expand as necessary.

Tooth                                                 [   ]
ENT                                                   [   ]
Skin                                                  [   ]
Heart                                                 [   ]
Lungs                                                 [   ]
Nervous System                                        [   ]
Varicose veins                                        [   ]
Genito urinary system                                 [   ]
Hernia                                                [   ]

Any other defects? ...................................................................................................................................................................



6.           Personal Details of Seafarer
                                                                                                       Audiogram (if equipment is available)
Height (without shoes) .......................m ......................cm
                                                                                                                          Khz        50         1,000      2,000      4,000      6,000       8,000
                                                                                                       Right ear          dB
Weight (stripped to waist) .........................................kilos
                                                                                                                          Khz        50         1,000      2,000      4,000      6,000       8,000
Chest Inspiration ................................................................cm                   Right ear          dB


Expiration ..............................................................................cm
                                                                                                                                              Eye Test
Pulse rate .....................................................................................
                                                                                   Distant                                 Un-       R6               L6                    Both 6
                                                                                                                          aided
Blood pressure systolic .......................................................... Vision                                 Aided      R6               L6                    Both 6


                                       5th Sound ............................................
                                                                                                                 Near Vision                                            Colour Vision
Results of urine test:
                                                                                                                                                                 Ishihare
Albumin ........................................................................................                    Un-aided N                                   Engineers modified

                                                                                                                      Aided N                                       Normal             Defective
Sugar ..............................................................................................



7.           Results of Medical Examination
             The Standards of Medical examination Regulations have been or have not been met.

                                                                                         Tick correct box
      A. Unrestrictive sea service                                  [ ]                                   E. Permanently                                   [ ]
      B. Restriction service only                                   [ ]                                   D. Indefinitely                                  [ ]

Restriction ...................................................................................                  (Review in ..................................................... weeks
                                                                                                          C. Temporarily                                   [ ]
Period of restriction ...............................................................                            (Review in ..................................................... weeks)

Medical Practitioner’s
Official Stamp
                                                                                                               Signature ..........................................................................

                                                                                                               Name...................................................................................
                                                                                                                                                 Block Letters

                                                                                                               Date.....................................................................................

				
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posted:7/19/2011
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