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Medical Book
Medical book
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Medical Book
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individually while serving on board a ship and should not be exposed to cther parties without the permission of the seafarer concerned. The contents of the medical records will be kept Confidential and shall ony be used to faciltate the treatment of the Seafarer. ‘The Medical Certificate (AS size), which is issued together with this medical records boolet, ‘meeting the requirements ofthe MLC, 2008, so contains only information direct relevent tothe functional requrements ofthe seafare’s cuties. Detals of any medical conditions denied or test results other than those listed herein are not recorded in the Certificate in accordance with the LOMO Guidelines on the Medical Examination of Seafarers, Appendix G. ‘The shipowner or manager or Master of the ship may collect the Medical Certfeae in respect of joining on board ship r por thereto. The ship Masta will maintain the Medical Certfcates ofall ‘crew members and make availabe on board for inspection by authorities. It the Medical Certificate expires during a voyage It may extend to be valid fora period of no ‘more than 3 months from the date of expry mentioned in it until the next port of call where ‘medical practioner recognised by the Party is avaiable. thas been confirmed that the seafarer has been informed ofthe content ofthe cartiicate and of ‘the ight to review in accordance with paragraph 6 of section A19 of the STCW Code and that ‘seaferer who has been refused @ medical certificate or has had a limitation imposed on his ‘ablity to work shall be given the epporunty to have a futher examination by another Independent medical doctor or by an independent medical referee in line with the appeals procedure is provided in section 15 of the Guidance for Seafarer Medical Examinations. and Cetiicatons (downloadable website: hitp://dma-mm org) issued by the Department of Marine ‘Adrinistation. * Seafarers are warmed net fo alter, correct or insert in any way tamper with the entries on this ‘certicate since the certfcato is in a format which minimizes the likelihood of alteration of is ‘contents or fraudulent copy. Name of Clinic: No.(116), 42'Street (Middle Block), ‘Address ciycon Mi p N soola Road. Botalita ,Myanmar 1 955 193240[viber} 65 193240vi CONFIDENTIAL (cocctoaracSuRE BEean, Secon so0goBa00) thoregiangS ypcBon ofeSospacowycSoobGGhEH oxcsobg Sal gfEarSohs Eaebare bol 1 nS occ nabs Groh iba “This medical certificate copy shoud be retained for atoastfve yeas fom the date of sous, ‘THE GOVERNMENT OF THE REPUBLIC OF THE UNION OF MYANMAR MINISTRY OF TRANSPORT AND COMMUNICATIONS DEPARTMENT OF MARINE ADMINISTRATION Issued under the provisions of the Intemational Convention on Standards of Training, Crtification and Watchkeeping for Seafarers (STCW), 1978, as amended and the Maritime Labour Convention (MLC), 2008, as amended Seafarer’s Book Number : 104250 Dateotissue: ay. Feb - 2004 Date of Expiry: an. feb - PoBe CONFIDENTIALCONFIDENTIAL |. Examinee’s Information FullNeme: Prone Ack ar Aan ‘Age:__26 Date of birth (deimmiyyyy)_a4_/ Mery iqa a Sex © mate O female Vaid PassportNo: ME e0zqt2 Seafarer’ Book No. 04230. Notional Reg. No: 12) Tha Ga. Ma CM) 131cp.95 Home address: _No . 34, i4/1¢ Quasto< AI Ayn Sans sh, shine pau Kaa yangeo| Department served on board (deck/engine/radio/cateringlother): fogjce Routine and emergency duties (if known) ‘Type of ship (e.g. general cargo, container, tanker, bulk, passenger) ‘Trade area (e.g. coastal, near-coastal, tropical, woridwide)CONFIDENTIAL, IL. Examinee’s Personal Declaration Have you ever had any of the following conditions? ‘Condition 1. Eyeision problem High blood pressure Hearl'vascular disease Heart surgery Varicose veins/piles ‘Asthmafbronchiis 7. Blood disorder 8. Diabetes 8. Thyroid problem 10. Digestive disorder 11. Kidney problem 12. Skin problem 13. "Allergies 14. Infectious/contagious diseases 15. Hemia 16. Genital disorders 17. Pregnancy 18. Sleep problems DAGOoOOoOKAoOoOoOoOoOoOoOooG Fs BSHegaseeoqgegn & a a a a a a goa 19. 20. a 2 23 2 26. 26, 2 2 29 20 34 2 2 4. {you answered ‘yes" fo any ofthe above questions, please give CONFIDENTIAL Do you smoke, use aloohol or drugs? Operation/surgery Epilepsy/seizures Dizziness/fainting Loss of consciousness Psychiatric problems, Depression ‘Attonpted suicide Loss of memory Balance problem ‘Severe headaches: Ear(hearing, tinnitus)nosethroat problems Restricted moblity Back or joint problem ‘Amputation Fractures/dislocations Poooooooogqn0o000000 8a 8a aé g 3 HSESB8saRCONFIDENTIAL Additional question Yes Oo 35, Have you ever been signed off as sick or repotated fom a ship? 36, Have you ever been hospitalized? o Gnu se 37. Have you ever been declared unfit forsea duty? a 38. Has your medical certicate ever been o restricted or revoked? Q 39. Are you aware that you have any medical o @ problems, diseases or ilnesses? 40. Do you fee! healthy and fit to perform the: a a duties of your designated ppositionloccupation? 41. Are you allergic to any medications? o @ Comments: 42, Are you taking any non-prescription or o @ prescription medications? yes", please list the medications taken, and the purpose(s) and dosages) CONFIDENTIAL | heteby certify that the personal declaration above is a tue statement fo the best of my knowledge. Signature of examinee a Date (ddtmm/yyyy): §— _ei__/._ fie _/-_eneg_— He i Eee eter et Name of witness: i WIN SAMA = 1.240 Previous Medical Records (ifany) MT 42 MUDICAL | hereby authorize the release of all my previous medical records from any health professionals, health institutons and public authorities to Dr. (the approved medical doctor). Signature of examinee: Date (dd mm iyyyy) Witnessed by (signature): Name of witness: Date and contact details for previous medical examination (if known):CONFIDENTIAL Il. Medical Examination (to be completed by the physician) Eyesight Use of glasses or contactlenses: Yes (] No Gr (if yes, specify which type and for what purpose) Visual acuity nadie Dignteyes| aie eyei| binocular Deen 10) O45. Near 3 3 ‘Aided Right eye | Lefteye | Binocular Distant ([ Near Visual Field ‘Normal Defective Right eye a o Left eye a Q Color vision Not tested {Normal C1 bouttiut D Detectve Hearing ure fone and audiomelry (Threshold valzes i dB) Ear S00Hz | 1,000Hz | 2,000Hz | 3,000 Hz Right 15 25 tet STE lacing] ‘Speech and whisper test (metres) [ear [Normal wisper | Right 3 1m Tet 4m se CONFIDENTIAL IV. Clinical findings (to be completed by the physician) Height:_[44 om; Weight__c5 kg, BMI:_3. Pulse rate:__9.q___Iminute; Rhythm Nose} Blood prossure: Systolic 120 _(mm Hg); Diastoio._&C_( mm Hg) Urinalysis: Glucose__Ni.__Protein:__Ni!__ Blood: _Ni Normal Abnormal 1. Head a o 2 Sinuses, nose, throat a a 3. Mouth/teeth a Oo 4 Ears (general) a Oo 5. Tympanic membrane a Oo 6 Eyes a o 7. Ophthalmoscopy a oO 8 Pupils am Oo 9. Eye movement a o 10. Lungs and chest a o 11. Breast examination a o12, 8. 14 18. 16 7, 18. 19. 20. a 22. 23. 24, CONFIDENTIAL, Heart skin Varicose veins Vascular (inc. pedal pulses) ‘Abdomen and viscera Hernia ‘Anus (not rectal exam.) G-U system Upper and lower extremities Spine (CIS, TIS and LIS) Neurologic (full brief) Psychiatric General appearance Bea a a a a a a og DoooooGoOoOoOoOoOaD CONFIDENTIAL Chest X-ray CINot performed [Yj Performed (date:__ei_/feb/_ecag) Results: Mead Size = Nasal . - cl ECG Results: sin Noxeral toot Ultrasound Results: _Noxenal —_ fintiags Other diagnostic test(s) and result(s) Test: Result: Pood GRUP A 5 Rbcwrve ross 5 CAMachecdd ) lab Hide HC tena. DRL = Neg Medical doctor's cortiments and assessment of fiiness, with reasons for any limitations: GE FIT For his concerning onboard dutyCONFIDENTIAL V. 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 ‘on the medical examination form, | declare the examinee medically C1 Fitfor lookout duty Not fit for ookout duty Deck Engine Catering -—_Other service Service Service Services Fit o a Gl a} Unfit a a o ao & without Restriction () With restrictions Visual aid required Yes & No Teg. specific positions, ype of ship, rade area). Medical certificate date of expiry (ddimmiyyyy)_20_/icb/_Boee Medical certificate date of issue (ddimmiyyyyy_f1_/ feb’ Bazg. Reg, Number of Medical certificate: _SSE/
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