Bahamas Maritime Authority

Medical Examination Form

CONFIDENTIAL FORM

Pre-sea Exam Periodic Exam

Name (last, first, middle): _____________________________________________________________

Date of Birth (day/month/year): / / Sex: male female

Nationality: _________________________________________________________________

Home address: _________________________________________________________________

Identity Document No: ______________________________________________________________

Type of Ship (e.g. container, tanker, passenger, fishing): _______________________________

Trade Area (e.g., coastal, tropical, worldwide): _________________________________________

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

1. Eye / Vision problem 18. Sleeping problems
2. High blood pressure 19. Do you smoke?
3. Heart / vascular disease 20. Operation / Surgery
4. Heart surgery 21. Epilepsy / Seizures
5. Varicose veins 22. Dizziness / Fainting
6. Asthma/bronchitis 23. Loss of Consciousness
7. Blood disorder 24. Psychiatric Problems
8. Diabetes 25. Depression
9. Thyroid problem 26. Attempted Suicide
10. Digestive disorder 27. Loss of Memory
11. Kidney problem 28. Balance Problem
12. Skin problem 29. Severe Headaches
Ear/Nose/Throat
13. Allergies 30.
Problems
Infectious / Contagious
14. 31. Restricted mobility
diseases
15. Hernia 32. Back problems
16. Genital disorders 33. Amputation
17. Pregnancy 34. Fractures / Dislocations

B103 Rev.04 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 15 of 28

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 Bahamas Maritime Authority

If any of the above questions were answered “yes,” please give details.

Additional questions

Yes No
35. Have you ever been signed off as sick or repatriated from a ship?
36. Have you ever been hospitalized?
37. Have you ever been declared unfit for sea duty?
38. Has your medical certificate ever been restricted or revoked?
39. 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
40.
position/occupation?
41. Are you allergic to any medications?

Comments.

42. Are you taking any non-prescription or prescription medications?

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

B103 Rev.04 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 16 of 28

Contact: [email protected]
+44 20 7562 1300
[email protected]
 Bahamas Maritime Authority

I hereby certify that the personal declaration above is a true statement to the best of my
knowledge.

Signature of Examinee: Date: ____ / /

(dd/mm/yyyy)

Witnessed By: ______________________ Name: ______________________

(Signature) (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 carrying out the medical examinations).

Signature of Examinee: Date: ____ / /

(dd/mm/yyyy)

Witnessed by: Name:

(Signature) (Typed or printed)

Medical Examination: Pre-Sea Periodic Other

Visual Acuity Visual Fields

SIGHT

Unaided Aided Normal Defective

Right Left Right Left Right

Binocular Binocular
Eye Eye Eye Eye Eye

Left
Distant
Eye

Near

Colour Vision: Not tested Normal Doubtful Defective

Pure Tone & Audiometry Speech & Whisper Test

HEARING

(threshold values in dB) (metres)

500 4,000 2,000 3,000 4,000 6,000

Normal Whisper
Hz Hz Hz Hz Hz Hz

Right Ear Right Ear

Left Ear Left Ear

Height: (cm) Weight: (kg)

Pulse rate: (bpm) Rhythm:

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

Urinalysis: Glucose: Protein:

B103 Rev.04 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 17 of 28

Contact: [email protected]
+44 20 7562 1300
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 Bahamas Maritime Authority

Normal Abnormal Normal Abnormal

Head Skin
Sinuses, Nose &
Varicose Veins
Throat
Mouth / Teeth Vascular
(inc. pedal pulses)

Ears Abdomen & Viscera

(general)
Tympanic
Hernia
Membrane
Eyes Anus
(not rectal exam).

Ophthalmoscopy G-U System

Upper & Lower
Pupils
Extremities
Eye movement Spine
(C/S, T/S & L/S)

Lungs and chest Neurologic

(full brief)

Breast
Psychiatric
Examination
General
Heart
Appearance

Chest X-Ray: Not performed Performed on: / /

(day/month/year)
Results:

Test Result

Medical practitioner’s comments:

Vaccination status recorded: Yes No

B103 Rev.04 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 18 of 28

Contact: [email protected]
+44 20 7562 1300
[email protected]
 Bahamas Maritime Authority

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

Deck Engine Catering Other

Service Service Service Services

Fit

Unfit

Without restrictions With restrictions

Describe Restrictions (e.g., specific positions, type of ship, trade area):

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)

Signature of Medical Practitioner: Official Stamp

Name of Medical Practitioner: Click or tap here to enter text.

(Printed)

Authorized By: Click or tap here to enter text.

B103 Rev.04 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 19 of 28

Contact: [email protected]
+44 20 7562 1300
[email protected]