APPLICATION FORM FOR MEDICAL EXAMINATION
SURNAME FIRST NAME MIDDLE NAME (S) SEX AGE WEIGHT GRADE OF THE OFFICER
MEDICAL HISTORY: DO ANY OF THE MEDICAL CONDITIONS LISTED APPLY?
INDICATE ADDITIONALCOMMENTS BELOW (33).
YES NO . YES NO YES NO
1. LOSS OS VISION 6. HYPERTENSION 11. EPILEPSY OF ATTACKS
2. COLOR BLINDNESS 7. CHEST PAINS 12. KIDNEY DISEASE
3. SEIZURES 8. DIABETES 13. VENEREAL DISEARE
4. FREQUENT HEADACHES 9. SHORTNESS OF BREATH 14. NARCOTICS HISTORY
5. HEART DIFFICULTLES 10. TUBERCULOSIS 15. OTHER ILLNESS
CLINICAL EVALUATION
NOTES: DESCRIBE EVERY ABNORMALITY AND ENTER PERTINENT ITEM NUMBER BEFORE EACH COMMENT (33)
NORMAL NORMAL
YES NO YES NO
16. HEAD, FACE, NECK, SCRIP 20. GENITO - URINARY (HEMATURIAL, PYURIA)
17. CHEST AN LUNGS 21. RECTUM (BLOOD, MASSES)
18. VASCULAR SYSTEM 22. LOWER EXTREMITIES (VARICOSITIES)
19. ABDOMEN AND VISCERA 23. APPERANCE & MENTAL STATE
24 VISION 25 COLOR PERCEPTION 26 HEARING
UNCORRECTED CORRECTED
RIGTH EYE 20/ 20/ BOOK LANTERN RIGHT EAR ____________
LEFT EYE 20/ 20/
BATH EYES 20/ 20/ YELLOW_______ RED__________ LEFT EAR______________
GREEN ________ BLUE _________
27. BLOOD PRESSURE 28. RESPIRATION / MIN. 28. PULSE
SYSTOLIC_________________ . YES NO
RATE REGULAR
DIASTOLIC_________________
LABORATORY FINDING
30. CHEST RADIOGRAPHY REPORT:
ALBUMIN SUGAR
31. URINALISIS: SPECIFIC GRAVITY 32. VDRL: POSITIVE NEGATIVE
(a) APPLICANTS WHO HAVE A MEDICAL HISTORY OF PAST OR PRESENT EPILEPSY, ACUTE VENERAL DESEASE, NEUROSYPHILIS, VARICOSE VEINS OR USE OF
NARCOTICS OR OTHER DISEASES ACCORDING TO MEDICAL CRITERIAN WILL BE DISQUALIFIED.
(b) CLINICAL EVALUATION:
b. 1. VISION REQUIREMENTS FOR:
DECK OFFICERS ENGINEER OFICERS RADIO OFFICERS
ABLE TO PERCEIVE RED, YELLOW
COLOR PERFECT COLOR PERCEPTION AND GREEN
UNCORRECTED 20/100 20/100 20/100
BOTH EYES, AT LEAST
CORRECTED 20/20 20/30 20/30
ONE EYE, AT LEAST
CORRECTED 20/40 20/50 20/50
OTHER EYE, AT LEAST
b. 2. SEVERELY IMPAIRED HEARING WILL DISQUALIFY THE APPLICANT.
b. 3. TAKING AGE INTO CONSIDERATION, THE APPLICANTS MUST HAVE NORMAL BLOOD PRESSURE, AND GOOD GENERAL PHYSICAL CONDITION
AS FOUND IN THE CLINICAL EVALUATION.
(c) LABORATOTY FINDINGS:
THE LABORATORY FINDINGS MUST CONFIRM SATISFACTORY GENERAL PHYSICAL CONDITIONS.
33. COMMENTS ON MEDICAL HISTORY AND CLINICAL EVALUATION
REMARKS, ACCORDING TO MEDICAL REQUIREMENTS.
SUMMARIZE BELOW ANY MEDICAL FINDINGS WHICH, IN YOUR OPINION, WOULD LIMIT THIS PERSON’S PERFORMANCE OF THE JOB DUTIES AND/OR
WOULD MAKE HIM A HAZARD TO HIMSELF OR OTHERS. CHECK THE LIMITING MEDICAL CONDITION, AND LIST THE DISQUALIFYING DEFECT BY ITEM
NUMBER.
(a) (b) (c) DEFECT BY ITEM NUMBER
NAME OF EXAMINING PHYSICIAN ADDRESS OF THE MEDICAL CENTER
NAME OF MEDICAL CENTER LICENSE No. DATE
D M Y
TELEPHONE TELEX:
IS THE APPLICANT PHYSICALLY QUALIFIED ACCORDING TO THE MEDICAL REQUIREMENTS? SI NO
DATE__________________________________________ ______________________________________________
SIGNATURE AND SEAL OF EXAMINING PHYSICIAN
IMPORTANT NOTICE:
THIS APPPLICATION FORM SHALL NOT BE CONSIDERED VALID FOR THE INSURANCE OF A CERTIFICATE OF COMPETENCY EXAMINATION CONFIRMATION FOR MERCHANT
MARINE SEAFARERS ABOARD 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 LABORATORY TESTS INDICATED IN THE FORM.
3. STCW95, Regulation I/9 – Medical Standards – Issue and Registration of Certificates, and Section B-I/9 Paragraph 11 “Notwithstanding these provisions, the
Administration may require higher standards than those given in table B-I/9-1 or table B-I/9-2 below”
4. ILO/WHO/A.2/1997 – Guidelines for the medical fitness review of seafarers previous to embarkment and periodics, of the International Labor Organization (ILO) and
the World Health Organization (WHO)
This form demands the minimum medical fitness conditions that sailors must fulfil .
