Seafarer Medical Report

TRICHY MARITIME MEDICAL CENTRE

No 4A/3, Williams Road, Cantonment, Tiruchirappalli, TamilNadu-620001.India.
Email: trichymaritime@gmail.com / Phone No: +91 9442380003 / +91 9994466055 / +91 4314061003
REPORT OF MEDICAL EXAMINATION OF SEAFARER BY APPROVED MEDICAL EXAMINER OF DG SHIPPING GOVT.OF INDIA
As per Merchant Shipping (Medical Examination) Rules 2000, ISM/STCW Code 1/98 and ILO convention 147

Name :

Sex :

Date of Birth :

Serial No :

PP/CDC

Rank

Vessel

Home Address

Type

Route

Company Name & Address

Medical History

Please answer the following to the best of your knowledge

Isthere any / present history of any of the following	Candidate		Examiner			Candidate		Examiner
Isthere any / present history of any of the following	Yes	No	Yes	No		Yes	No	Yes	No
Service one side headache (Migraine)					Hernia / Hydrocoele / Appendicitis
Head Injury / Concussion / Loss of Memory					High/Low Blood Pressure / Heart Disease
Eye Vision Problems (Glass etc.)					Asthma / Bronchitis / Tuberculosis
Fits/Epilepsy/Dizziness/Fainting					Allergy / Skin Disease
Hearing Impairment					Infection / Contagious Disease
Ear / Nose / Throat Problems					Addiction to Alcohol / Drugs / Tobacco
Stomach / Bowel Disorders					Fracture/ Dislocation/Injury/ Amputation
GALL Stones / Kidney Disorder's					Major / Minor Operation
Jaundice / Liver Disease					Diabetes
Piles / Varicose Writes					Nervous / Mental disease / sleep disorder
Blood Disorder					Malignant diseases (Cancer)
Female Disorder					Signed off on medical grounds/Declared Unfit

Notes

Medical Examination

Height (cms)

Weight (kgs)

Chest insp-exp

Blood Pressure in mm of Hg

Pulse beats/min

Resp Rate / min

General Appearance

Distance Vision

Uncorrected

Corrected

Field of Vision

Audiometry

KHz

500

1000

2000

3000

4000

5000

6000

8000

Colour Vision

Hearing

Right Ear

Left Ear

Systemic Examination	Notes
Head & Neck	Fit for	Systemic Examination
Eyes		Cardiovascular System
Ear / Nose / Throat		Per Abdomen
Teeth / Oral Cavity		Genito Urinary System
Muscle Skeletal System		Others
Nervous System		Hernia / Hydrocele
Reflex		Varicose Veins
		Fissure / Fistula / Piles

Investigations

Blood	Result	Normal Range
Hemoglobin
Total WBC
Platelets
ESR
SGPT
S. Cholesterol
S. Triglycerides
Blood Sugar
Malaria
VDRL
HIV I & II
Hbsag
X-ray Chest
ECG
Blood Group

Urine	Result
Color
Specific Gravity
pH
Albumin
Sugar
Bile Pigment
Bile Salts
Occult Blood
RBC Cells
Leucocytes
Pus Cells
Others
USG
Spirometry
TMT
Drugs of Abuse

Neu Lymp Eos Mono Baso

Result Medical Examination

On the basis of the examinee history, clinical and diagnostic tests. I, hereby declare the examinee medically

FIT FOR SEASERVICE [] UNFIT FOR SEA SERVICE [] TEMPORARILY UNFIT FOR SEA SERVICE [] PERMANENTLY UNFIT FOR SEASERVICE [] SHOULD BE RE-EXAMINED [ ](DAYS/WEEK/MONTHS)

Remarks / Recommendations:

This certificate is valid till:

Doctor’s Signature

DATE:

TRICHY MARITIME MEDICAL CENTRE

No 4A/3, Williams Road, Cantonment, Tiruchirappalli, TamilNadu-620001.India.
Email: trichymaritime@gmail.com / Phone No: +91 9442380003 / +91 9994466055 / +91 4314061003

Medical Certificate for Service at Sea

(Seafarer’s Last name, First name and Middle name)

DATE OF BIRTH (DD-MM-YYYY)

GENDER (MALE / FEMALE)

(Number of CDC / PP /INDOS other valid identification document - with type of document)

has been examined by

(Name of Medical Examiner and Approval No)

And has been found fit for service at sea in the job of

APPENDIX IV

Choose Photo

(Nationality)

The hearing and sight of the seafarer concerned, and the colour vision in the case of a seafarer to be employed in capacities Where fitness for the work to be performed is liable to be affected by defective colour vision, are satisfactory; and
The seafarer concerned is not suffering from any medical condition likely to be aggravated by service at sea or to render the Seafarers unfit for such service or to endanger health of other persons on board.
The seafarer complies with the requirements specified in Table A – 1/9- of STCW Code (i.e. Minimum in service eyesight Standards for seafarers) Table B-I/9 of the STCW Code (i.e. Assessment of minimum entry level and in – service physical abilities for seafarers) and Regulation 1.2 Standard A-1.2 & Guideline B-1.2 of the MARITIME LABOUR CONVENTION 2006.

at (Date & Place of Medical Examination)

(Signature of the Medical Examiner)

(Serial number of the Certificate)

This Certificate expires on*
(Day, Month, Year) *

(* Not more than 2 years from the date of issue, unless the seafarersis under the age of 18, in which case the maximum period of validity of the Medical Certificate shall be 1 year).

If the period of validity of the medical certificate expires in the course of voyage, the medical certificate shall continue in force until the next port of call where an approved Medical Examiner is available and the seafarer can obtain a medical certificate, provided that period of such extension shall not exceed 3 months.

TRICHY MARITIME MEDICAL CENTRE

No 4A/3, Williams Road, Cantonment, Tiruchirappalli, TamilNadu-620001.India.
Email: trichymaritime@gmail.com / Phone No: +91 9442380003 / +91 9994466055 / +91 4314061003

SIGHT TEST CERTIFICATE

New Entry*/Periodic*

REFERENCE NO.:
Full Name:
Rank:
PP/CDC/ID No.:
Date and Place of Birth:
Colour of Eyes:
Identification Notes:

APPENDIX V

Part B

		Right Eye	Left Eye	Both Eyes	Result
Distance Vision	Unaided
Distance Vision	Aided
Near Vision	Unaided
Near Vision	Aided
Field of Vision	Horizontal Plane
Field of Vision	Vertical Plane
Colour of Vision	Ishihara
Colour of Vision	Lantern/Others

I, hereby certify that the above-mentioned candidate has the eye sight standard for designated as set out in for seafaring occupation.

Candidate’s Signature

(Signature of the Medical Examiner)

at (Date & Place of Medical Examination)

Notes: 1. This certificate is valid for years from the above date.New entry sight test certificate should Be retained by the candidate till HER / HIS Sea Career. 2. Seafarers aggrieved by the decision of the Medical Examiner may appeal as per the provision of the M. S. (Medical Examination) Rules, 2000 As amended

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