Minimum Test for the conduct of medical examination

1. Periodic Medical Examination (Sea Service & Certification purposes)

(A) Mandatory Examination and Tests (Sea Service)

Physical Examination: Weight, Height, Temperatures, Blood Pressure, pulse rate, Sight, Hearing , Oral Health  ,general appearance  and systemic examination of whole body.

Blood Tests  :-

BI CBC

BI ESR

RBS / FBS

SGOT

SGPT

SGGT

S Creatinine & Urea

S Cholesterol

S Triglycerides

Blood group & Rh factor( tested only once, need not be repeated)

Test for Hepatitis B (Hb_sAg) and C

VDRL

HIV I& II

X-ray chest

Urinalysis

ECG  

Drug & Alcohol Screening – Morphine, Barbiturates, Marijuana, Cocaine, Amphetamines, Alcohol

Audiometric

Stool R/E & Widal for food handlers

Ultrasound (USG) of the Abdomen & Pelvis

(B) Optional Tests-

Psychometric evaluation on case to case basis

Stress test

2D echo Doppler study (for heart patient)

Glycosylated (Hb1Ac)

Spirometry

3. Mandatory Examination and Tests (Certification of Competency and other endorsements) subject to the candidate not having medical certificate.

(i) Physical Examination: Weight, Height, pulse rate, Temperatures, Blood Pressure, Sight, Hearing ,Oral Health  ,general appearance  and systemic examination of whole body.

(ii)Blood Tests  :-

BI CBC

BI ESR

RBS / FBS

SGOT

SGPT

SGGT

S Creatinine

S Cholesterol

S Triglycerides

Blood group & Rh factor

Test for Hepatitis B (Hb_sAg) and C

BI VDRL

HIV I& II

(iii)X-ray chest (PA)

(iv)ECG

(v) Urine analysis

4. Pre-sea Medical Examination(New Entrant)-

(A) Mandatory Examination and Tests

Physical Examination: Weight, Height, Temperatures, pulse rate, Blood Pressure, Sight ,Hearing , Oral Health , general appearance & systemic examination of the whole body .

Blood Tests  :-

BI CBC

BI ESR

SGOT

SGPT

SGGT

S Creatinine

S Cholesterol

S Triglycerides

Blood group & Rh factor CL

Test for Hepatitis B (Hb_sAg) and C

BI VDRL

HIV I& II

X-ray chest (PA)

Urinalysis

Drug & Alcohol Screening – Morphine, Barbiturates, Marijuana, Cocaine, Amphetamines, Alcohol

Audiometric

Psychometric test conducted by any qualified psychiatrist / psychologist

Ultrasound (USG) of the Abdomen & Pelvis

(B) Optional Tests-

Glycosylated (Hb1Ac)

RBS/FBS(Blood test)

ECG

Stress Test if deem necessary

2D echo Doppler study Psychometric evaluation on case to case basis

5. Vaccination under WHO or other country’s regulations as applicable-

(i) Vaccination at the time of Pre-sea and Periodic test:- Seafarers shall be vaccinated according to the requirements indicated in the           WHO publication, International Travel & Health;  vaccination requirement and health advise updated periodically.

(ii) Yellow fever is now only decease for which vaccination is statutory requirement in some countries and for which an International certificate of vaccination is required. Responsibility to provide immunization shall rest with the training institute and the employer of the seafarer as the case may be.

Yellow Fever –

At a WHO designated Yellow Fever Centre only.  Booster once every 10 years for seafarer and new entrant.

MEDICAL EXAMINATION OF SEAFARERS

Examinee’s Declaration

PS: 1. The seafarer shall not suppress medical information and declare

correct and proper medical information to the medical examiner to the best of his knowledge and belief.

1.  In case of any wrongful Act or misrepresentation/suppression of material fact(s) of information or infringement the concerned seafarer shall be fully responsible/liable for the consequences/ damages / penalties as per the provisions or  the applicable laws.

1.       Name (last, first, middle): _____________________________________________

2.       Date of birth (day/month/year):                   .. /..  /….

3.       Sex:   __ Male __ Female

4.       Home address: _______________________________________________________

5.       Method of confirmation of identity, e.g. Passport No./Seafarer’s book No. or other relevant identity document No.: _____

6.       Department (deck/engine/radio/food handling/other): _____

7.       Routine and emergency duties (if known): _____

8.       Type of ship (e.g. container, tanker, passenger): _____

9.       Trade area (e.g. coastal, tropical, worldwide): _____

10.     Examinee’s personal declaration

(Assistance should be offered by medical staff)

11.     Have you ever had any of the following conditions?

Condition                                                                       Yes              No

• Eye/vision problem
• High blood pressure
• Heart/vascular disease
• Heart surgery
• Varicose veins/piles
• Asthma/bronchitis
• Blood disorder
• Diabetes
• Thyroid problem
• Digestive disorder
• Kidney problem
• Skin problem
• Allergies
• Infectious/contagious diseases
• Hernia
• Genital disorder
• Pregnancy
• Sleep problem
• Do you smoke, use alcohol or drugs?
• Operation/surgery
• Epilepsy/seizure
• Dizziness/fainting
• Loss of consciousness
• Psychiatric problems
• Depression
• Attempted suicide
• Loss of memory
• Balance problem
• Severe headaches
• Ear (hearing, tinnitus)/nose/throat problem
• Restricted mobility
• Back or joint problem
• Amputation
• Fractures/dislocations

If you answered “yes” to any of the above questions, please give details:

12. Additional questions                                                                  Yes     No

• Have you ever been signed off as sick or repatriated from

a ship?

• Have you ever been hospitalized?
• Have you ever been declared unfit for sea duty?
• Has your medical certificate even been restricted or revoked?
• Are you aware that you have any medical problems,

diseases or illnesses?

• Do you feel healthy and fit to perform the duties of your

designated position/occupation?

• Are you allergic to any medication?

Comments:

13. Additional questions                                                            Yes       No

• Are you taking any non-prescription or prescription

medications?

If yes, please list the medications taken, and the purpose(s) and dosage(s):

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 practitioner).

Signature of examinee: _______________________ Date (day/month/year): ../../….

Witnessed by (signature): ___________ Name (typed or printed): _________________

Date and contact details for previous medical examination (if known): _________

———————————————————————————————————————————————————————-­­­­­­­­­­­­­­­­­­——————————

14.     MEDICAL EXAMINATION

• Sight

Use of glasses or contact lenses: Yes/No (if yes, specify which type and for what purpose)

___________________________________________________________________________

• Visual acuity

___________________________________________________________________________

                        Unaided                                             Aided

Right eye    Left eye    Binocular                   Right eye   Left eye Binocular

___________________________________________________________________________

Distant

Near

___________________________________________________________________________

• Visual fields

__________________________________________________________________________

Normal             Defective

________________________________________________________________________

Right eye

Left eye

___________________________________________________________________________

• Colour vision

 Not tested            Normal                Doubtful              Defective

• Hearing

___________________________________________________________________________

Pure tone and audiometry (threshold values in dB)

___________________________________________________________________________                           500 HZ              1 000 HZ           2 000 HZ           3 000 HZ

______________________________________________________________________________

Right ear

Left ear

______________________________________________________________________________

• Speech and whisper test (metres)

______________________________________________________________________________

Normal        Whisper

______________________________________________________________________________

Right ear

Left ear

______________________________________________________________________________

15.     Clinical findings

Height: _____ (cm) Weight: _____ (kg)

Pulse rate: _____/(minute) Rhythm: _____

Blood pressure: Systolic: _____ (mm Hg) Diastolic: _____ (mm Hg)

Urinalysis: Glucose: _____ Protein: _____ Blood: _____

______________________________________________________________________________

Normal           Abnormal

______________________________________________________________________________

Head

Sinuses, nose, throat

Mouth/teeth

Ears (general)

Tympanic membrane

Eyes

Ophthalmoscopy

Pupils

Eye movement

Lungs and chest

Breast examination

Heart

Skin

Varicose veins

Vascular (inc. pedal pulses)

Abdomen and viscera

Hernia

Anus (not rectal exam)

G-U system

Upper and lower extremities

Spine (C/S, T/S and L/S)

Neurologic (full/brief)

Psychiatric

General appearance

16.     Chest X-ray

 Not performed               Performed on (day/month/year): ../../….

Results:

17.     Other diagnostic test(s) and result(s):

Test:                               Result:

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

18.     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  Other services (training/examination)

Deck service  Engine service       Catering service     Other services

Fit                                                                                                   

Unfit                                                                                               

Without restrictions  with restrictions   Visual aid required      Yes        No

Describe restrictions (e.g., specific position, type of ship, trade area & others as applicable):

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

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

Number of medical certificate: ________________________________________________

Signature of approved medical examiner: _____________________________________

Approved Medical examiner information (name, license number, approval number, address)