GENERAL DIRECTORATE OF MERCHANT MARINE

APPLICATION FORM FOR MEDICAL EXAM

FOR FLAG STATE INSPECTOR

SURNAME FIRST NAME MIDDLE (NAME) SEX AGE WEIGHT GRADE OF

THE
OFFICER
MEDICAL HISTORY: DO ANY OF THE MEDICAL CONDITIONS LISTED APPLY?
INDICATE ADDITIONAL COMMENTS BELOW (33)

YES NO YES NO YES NO

1. LOSS OF VISION 6. HYPERTENSION 11. EPILEPSY ATTACKS

2. COLOR BLINDNESS 7. CHEST FAIN 12. KIDNEY DISEASE

3. SEIZURES 8. DIABETES 13. VENEREAL DISEASE

4. FRECUENT HEADACHES 9. SHORT NESS OF BREATH 14. NARCOTICS HISTORY

5. HEART DIFFICULT 10. TUBERCULOSIS 15. OTHER ILLNESS

CLINICAL EVALUATION
NOTES: DESCRIBE EVRY ABNORMALITY AND ENTER PERTINENT ITEM NUMBER BEFORE EACH COMMENT (33)
Normal Normal
YES NO YES NO
16. HEAD, FACE, NECK 20. GENITO- URINARY (HEMATURIAL PYURIA)

17. CHEST AND LUNGS 21. RECTUM, (BLOOD MASSES)

18. VASCULAR SYSTEM 22. LOWER EXTREMITIES (VARICOSES)

19. ABDOMEN AND VISCERA 23. APPERANCE & MENTAL STATE

24. VISION 25. COLOR PERCEPTION 26. HEARING

RIGHT EYES UNCORRECTED CORRECTED BOOK LANTERN

LEFT EYES 20% 20% RIGHT EAR ________________________
BOTH EYES 20% 20% YELLOW ____________ RED _____________
20% 20% LEFT EAR _________________________
GREEN _______________ BLUE ____________
27. BLOOD PREASURE 28. RESPIRATION/ MIN 29. PULSE
SYSTOLIC _________________ YES NO
DIASTOLIC _________________ RATE________________ REGULAR

LABORARTORY FINDING
30. CHEST RADIOGRAPHY REPORT:
X- RAY

31. ALBUMIN SUGAR 32.

URINALISIS: SPECIFIC GRAVITY VDRL: POSITIVE NEGATIVE

MEDICAL REQUIREMENT

(A) APPLICANTS WHO HAVE A MEDICAL HISTORY OF PAST OR PRESENT EPILEPSY, ACUTE VENERAL DESEASE, NEURO SYPHYLIS, VARICOSE VEINS
OR USE OF NARCOTICS OR OTHER DESEASE ACCORDING TO MEDICAL CRITERION WILL BE DISCUALIFIED.
(B) CLINICAL EVALUATION
B1.

DECK OFFICER ENGINEER OFFICERS RADIO OFFICERS

COLOR PERFECT COLOR PERCEPTION ABLE TO PERCEIVE
RED, YELLOW AND GREEN
UNCORRECTED 20/100 20/100 20/100
BOTH EYES, AL LEAST
CORRECTED 20/20 20/30 20/30
ONE EYES, AT LEAST
CORRECTED 20/40 20/50 20/50
OTHER EYES, AT LEAST

B2. SEVERALY IMPAIRED HEARING WILL DISQUALIFY THE APPLICANT

B3. TAKING AGE INTO CONSIDERATION, THE APPLICANTS MUST HAVE NORMAL BLOOD PRESSURE, AND GOOD GENERAL PHYSICAL
CONDITION AS FOUND IN THE CLINICAL EVALUATION.

(C) LABORATORY FINDINGS:

THE LABORATORY FINDINGS MUST CONFIRM SATI8SFACTORY GENERAL PHYSICAL CONDITIONS.

COMMENTS ON MEDICAL HISTORY AND CLINICAL EVALUATION

__________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________ _
__________________________________________________________________________________________________________________________________________

REMARK: ACCORDING TO MEDICAL REQUIREMENTS

SUMMARIZE BELOW ANY MEDICAL FINDINGS WHICH, IN YOUR OPINION, WOULD LIMIT THIS PERSON PERFORMANCE OF THE JOB DUTIES AND OR WOULD
MAKE HIM A HAZARD TO HIMSELF OR OTHERS. CHECK THE LIMITED MEDICAL CONDITION AND LIST THE DISQUALIFYING DEFECT BY ITEM NUMBER.

(A) (B) (C ) DEFECT BY ITEM NUMBER

________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________

NAME OF EXAMINING PHYSICIANS ADDRESS OF THE MEDICAL CENTER

TELEPHONE: TELEFAX

NAME OF MEDICAL CENTER LICENSE Nª. DATE

D M Y

33. SI NO
IS THE APPLICANT PHYSICALLY QUALIFIED ACCORDING TO THE MEDICAL REQUIREMENTS?

___________________________________________ _______________________________________________
DATE SIGNATURE AND SEAL OF EXAMINING PHYSICIAN
IMPORATANT NOTICE:
THIS APPLICATION FORM SHALL NOT BE CONSIDERED VALID FOR THE ISSUANCE OF A CERTIFICATE OF COMPETENCY EXAMINATION CONFIRMATION FOR
MERCHANJT MARINE SEAFABERS ABOARDS PANAMANIAN VESSELS, IF IT DOES NOT COMPLY WITH ANY OF THE FOLLOWING REQUIREMENTS:
1. THE LACK OF ADDRESS, TELEPHONE NUMBER STAMP AND/OR SIGNATURE OF THE PHYSICIAN.
2. INCORRECTLY FILLED OUT OR THE LACK OF ANY OF THE LAQBORATORY TEST INDICATED IN THE FORM.

Elaborado por: Jefe de la Sección de Inspección de Revisado por: Jefe del Depto. de Navegación y Seguridad Aprobado por: Director General de Marina
Bandera. Marítima. Mercante.
N° Control: F-GPASI-01-06 Versión: 00 ; fecha: 27 de Mayo de 2009 Página: 1 de 1