NAME:

D.O.B:

Crew ID:

Position:

Date of
Name of vaccine Doctor’s Signature & Stamp
vaccination
Priorix (MMR) Vaccine (0.5ml)
Batch No:
Exp:

Varilrix (Varicella) Vaccine (0.5ml)

Batch No:
Exp:

(1st dose)

Stamaril (yellow fever) Vaccine (0.5 ml)

Batch No:
Exp:

Tetanus Vaccine (0.5ml)

Batch No:
Exp:

Varilrix (Varicella) Vaccine (0.5ml)

Batch No:
Exp:

(2nd dose)
 SCHEDULE II

Pre-sea and Periodic Medical Fitness Examinations for Seafarers

Name(last, first, middle):

Date of Birth(day/month/year): Sex: Male Female

Home address:

Passeport No./Discharge Book No.:

Type of Ship(container, tanker, passenger, fishing):

Trade area (e.g., coastal, worldwide):

Examinee’s personal declaration:

(Assistance should be offered by medical staff)

Have you ever any of the following conditions

Conditions Yes No Conditions Yes No

1 Eye/VISION problem 18 Sleep problems

2 High blood pressure 19 Do you smoke?

3 Heart/ vascular problem 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

 Yes No Yes No

11 Kidney problem 28 Balance problem

12 Skin problem 29 Severe Headaches

13 Allergies 30 Ear/nose/throat problems

14 Infectious/contagious 31 Restricted mobility

diseases
15 Hernia 32 Back problems

16 Genital disorders 33 Amputation

17 Pregnancy 34 Fractures/dislocations

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 illness?

40 Do you feel healthy and fit to perform the duties of your designated position/occupation?

41 Are you allergic to any medications?

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

If yes, please list the medications taken and 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’s:

Date : ___/___/___

Witness by: (Signature) ____________________________________________________________

Name: (Typed or Printed) ____________________________________________________________

Medical examination

Pre-sea Periodic Other

SIGHT

Visual fields

Normal

Defective

Right eye

Left eye

Colour vision: Not tested Normal Doubtful Defective

HEARING

Speech and whisper test

Pure tone and audiometry (threshold values in dB)
(meters)
1,000 2,000 3,000 4,000 6,000
500 Hz Normal Whisper
Hz Hz Hz Hz Hz

Right Right
ear ear

Left Left
ear ear

Height: (cm) Weight: (kg)

Pulse rate: /(minute) Rhythm:
Blood pressure: Systolic: (mm Hg) Diastolic: (mm Hg)
Urinalysis:

Glucose :

Protein :

Others :

Physical Examination :

Normal Abnormal Normal Abnormal

Head Varicose veins

Sinuses, nose, throat Vascular(inc. pedal pulses)

Mouth/teeth Abdomen and viscera

Ears (general) Hernia

Tympanic membrane Anus (not rectal exam)

Eyes G-U system

Opthalmoscopy Upper and lower extremities

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

Eye movement Neurologic (full brief)

Lungs and chest Psychiatric

Breast examination General appearance

(if applicable)
Heart (ECG)

Skin

Chest X-ray : Performed on (day/month/year):

BLOOD Test Results

BLOOD Test RESULTS

FBC

UREA

VDRL, TPHA

Blood Group

HIV

HEPATITIS B Surface Antigen

LFT

Serum Gamma GT

Others

Medical examiner’s comments:

Vaccination status recorded Yes No

(See attached vaccination records)
 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 service Engine service Catering service Other services

Fit

Unfit
Without restrictions: With restrictions:

Action taken by medical examiner (e.g., referral):

Place of examination:

Date of examination(day/month/year) (two years validity):

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

Official stamp (also print name of medical examiner if not legible):

Signature of medical examiner:

 SCHEDULE III
Medical Fitness Examination for Seafarers

Medical certificate for service at sea

Name(last, first, middle)

Date of Birth(day/month/year) Sex: Male Female

Home address:

Passport No./Discharge Book No.:

I have evaluated the above-named examinee according to

(National Standards)

On the basis of the examinee’s personal declaration, my clinical examination and diagnostic test

results recorded on the medical examination form, I declare the examinee:

Fit for look-out duty Not fit for look-out duty

Deck service Engine service Catering service Other services

Fit

Unfit
Without restrictions: With restrictions:

Describe restrictions (e.g., specific position, type of ship, trade area)

Place of examination:

Date of examination(day/month/year):

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

Official stamp (also print name of medical examiner if not legible):

Signature of medical examiner:

I acknowledge that I have been informed of the outcome of the medical examination.
Examinee’s signature:
(To be signed in the presence of the medical examiner)

Note: Period of validity not exceeding two years from the date of issue except if found otherwise by the medical practitioner

Carrying the Medical examination