| Last Name of Applicant: | First Name of applicant: | Middle Initial |
| Seafarers Number (if assigned) |
| Date of Birth: | Place of Birth: | Sex: |
| Month | Day | Year | City | Country | [ ] : Male |
| [ ] : Female |
| Examination for Duty As: | Mailing Address of Applicant: |
| [ ] : Master | [ ] : Radio Officer |
| [ ] : Mate | [ ] : Rating |
| [ ] : Engineer |
| MEDICAL EXAMINATION |
| Height: | Weight: | Blood Pressure: | Pulse: | Respiration: | General Appearance: |
| Vision: | Right Eye: | Left Eye: Hearing: | Hearing |
| With Glasses |
| Without Glasses | | |
| | Right Ear | Left Ear |
| Colour Test Type:[ ]: Book [ ] : Lantern | Check if Colour Test is Normal: Yellow Red Green Blue |
| Head and Neck: | Heart (Cardiovascular): |
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| Lungs: | Speech (Is speech unimpaired for normal voice communication?): |
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| Extremities: |
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| Upper | Lower |
| Is applicant suffering from any disease likely to be aggravated by, or to render him/her unfit for service at sea or likely to endanger the health of other persons on board? (Give further details overleaf if necessary): |
| This is to certify that a physical examination was given to: [Name of Applicant] |
| The Shipping (Medical Fitness) Regulations have been/have not been* met and a Medical Certificate has/has not* been issued. |
| Delete as appropriate and tick box below |
| A Unrestricted sea service [ ] |
| A (T) Unrestricted sea service, subject to medical supervision [ ] |
| B Restrictive Service only [ ] |
| Details of any Restriction |
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| Period of restriction |
| C. Temporarily | [ ] (Review in (max. four) weeks) |
| D. Indefinitely | [ ] (Review in (max. six ) months) |
| E. Permanently | [ ] |
| Name and Degree of Medical Doctor |
| Address |
| Name of Medical Doctor's Certificating Authority |
| Date of Issue of Medical Doctor's Certificate |
| Signature of Medical Doctor |
| Date |
| |
| Signature of Applicant | Date of Application: |
| The signature should be affixed in the presence of the examining Medical Doctor and signed without touching any of the box lines. |
Remarks to or further details of Medical Examination:
(to be completed by examining Medical Doctor) |
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