Medical Examination Report
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CHROMAGEN LENSES MUST NOT BE WORN Have you ever been declared unfit for duty at sea Yes No If yes, state when, for how long and for what reason Rating-Deck (Rating - Navigational Watch / Able Seafarer Deck) Rating-Engineering (Rating - Engine Room Watch / Able Seafarer - Engine ) Catering (Marine Cook) Other (specify) Denotes Hepatitis A arrangements apply Has your Certificate of Medical Fitness ever been restricted or cancelled or have you ever been declared unfit Yes No Personal history Are you in good health now Yes No Do you drink alcohol Yes No Yes No Yes No If yes, give details If yes, how much and how often Do you smoke tobacco If no, have you smoked in the past Yes No If yes, give details Have you been absent from work due to sickness or injury for more than 14 consecutive days over past two years Yes Have you ever been signed off as sick or repatriated from a ship No If yes, give details AMSA 232 (6/16) 1 of 4 Have you now, or have you previously had any of the following: • • • • • Anxiety or depression Migraine or persistent headaches Epillepsy or fits Poliomyelitis or other paralysis Attack of unconsciousness or weakness, dizziness or turns Yes • • • • • • • • High blood pressure Disease of the heart, arteries or blood vessels Operation on the heart Anaemia or any other disease of the blood Swelling of the ankles Palpitations Varicose veins or abnormal bleeding Rheumatic fever • • • • • • • • • Disease of the liver (including jaundice or hepatitis) Disease or ulcer of the stomach or duodenum Recurrent abdominal pain/persistent indigestion Appendicitis Gallbladder disease Disease of the bowels Haemorrhoids (piles) Hernia (rupture) Recent change in weight • • • • • • • Asthma Bronchitis or emphysema Tuberculosis Persistent breathlessness Persistent cough Collapsed lung Other lung disease/abnormal x-ray • • • • • Infection of bladder Kidney disease or kidney stone Difficulty in passing urine Any abnormality of the urine Sexually transmitted disease Yes Y
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