Bahamas Maritime Authority

Annex II - Medical Examination Form

CONFIDENTIAL FORM

Pre-sea Exam Periodic Exam

Name (last, first, middle):

Date of birth (day/month/year): / / Sex: male female

Nationality

Home address: Identity document No.:

Type of ship (e.g. container, tanker, passenger, fishing):

Trade area (e.g., coastal, tropical, worldwide):

Examinee’s personal declaration

(Assistance should be offered by medical staff)

Have you ever had any of the following conditions:

Condition Yes No Condition Yes No

1. Eye/vision problem 18. Sleeping problems

2. High blood pressure 19. Do you smoke?

3. Heart/vascular disease 20. Operation/surgery

4. Heart surgery 21. Epilepsy/seizures

5. Varicose veins 22. Dizziness/fainting

6. Asthma/bronchitis 23. Loss of consciousness

7. Blood disorder 24. Psychiatric problems

8. Diabetes 25. Depression

9. Thyroid problem 26. Attempted suicide

10. Digestive disorder 27. Loss of memory

11. Kidney problem 28. Balance problem

12. Skin problem 29. Severe headaches

13. Allergies 30. Ear/nose/throat problems

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14. Infectious/contagious diseases 31. Restricted mobility

15. Hernia 32. Back problems

16. Genital disorders 33. Amputation

17. Pregnancy 34. Fractures/dislocations

If any of the above questions were answered “yes,” please give details.

Additional questions

Yes No

35. Have you ever been signed off as sick or repatriated from a ship?

36. Have you ever been hospitalized?

37. Have you ever been declared unfit for sea duty?

38. Has your medical certificate ever been restricted or revoked?

39. Are you aware that you have any medical problems, diseases or illnesses?

40. Do you feel healthy and fit to perform the duties of your designated
position/occupation?

41. Are you allergic to any medications?

Comments.

42. Are you taking any non-prescription or prescription medications?

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If yes, please list the medications taken and the purpose(s) and dosage(s).

I hereby certify that the personal declaration above is a true statement to the best of my knowledge.

Signature of examinee: Date (day/month/year): / /

Witnessed by: (Signature) Name: (Typed or printed)

I hereby authorize the release of all my previous medical records from any health professionals,
health institutions and public authorities to Dr. (the approved medical practitioner carrying out the
medical examinations).

Signature of examinee: Date (day/month/year): / /

Witnessed by: (Signature) Name: (Typed or printed)

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Medical examination

Pre-sea Periodic Other

Sight

Visual acuity Visual fields

Unaided Aided Normal Defective

Right Left Binocular Right Left Binocular Right

eye eye eye eye eye

Distant Left
eye

Near

Color vision: Not tested Normal Doubtful Defective

Hearing

Pure tone and audio metry (threshold values in dB) Speech and whisper test (metres)

500 4,000 2,000 3,000 4,000 6,000 Normal Whisper

Hz Hz Hz Hz Hz Hz

Right ear Right ear

Left ear Left ear

Height: (cm) Weight: (kg)

Pulse rate: (/minute) Rhythm:

Blood pressure: Systolic: (mm Hg) Diastolic: (mm Hg)

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Urinalysis: Glucose: Protein:

Normal Abnormal Normal Abnormal

Head Skin

Sinuses, nose, throat Varicose veins

Mouth/teeth Vascular (inc. pedal pulses)

Ears (general) Abdomen and viscera

Tympanic membrane Hernia

Eyes Anus (not rectal exam.)

Opthalmoscopy G-U system

Pupils Upper and lower extremities

Eye movement Spine (C/S, T/S and L/S)

Lungs and chest Neurologic (full brief)

Breast examination Psychiatric

Heart General appearance

Chest X-ray: Not performed Performed on (day/month/year): / /

Results:

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Other diagnostic test(s) and result(s):

Test Result

Medical practitioner’s comments:

Vaccination status recorded: Yes No

Assessment of fitness for service at sea

On the basis of the examinee’s personal declaration, my clinical examination and the diagnostic test
results recorded above, I declare the examinee medically:

Fit for look-out duty Not fit for look-out duty

Deck service Engine service Catering service Other services

Fit

Unfit

Without restrictions With restrictions

Describe restrictions (e.g., specific positions, type of ship, trade area)

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Contact: [email protected]
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 Bahamas Maritime Authority

Action taken by medical examiner (e.g., referral):

Place of examination:

Date of examination (day/month/year): / /

Medical certificate’s date of expiration (day/month/year): / /

Official stamp:

Signature of medical practitioner:

Name of medical practitioner: (Typed or printed)

Authorized by:

B103 Rev.03 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 18 of 22

Contact: [email protected]
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 Bahamas Maritime Authority

Annex III: Draft Format of a Seafarer Medical Certificate

SEAFARER MEDICAL CERTIFICATE

(issued under the authority of authorising country details.)

This Medical Certificate has been issued in accordance with the provisions of the( International Convention on Standards of Training,
Certification and Watch-keeping for Seafarers STCW 1978, as amended (STCW) Regulation I/9, Maritime Labour Convention 2006
(MLC 2006) Regulation 1.2 and regulation xxx of the authorising country)*as applicable

SEAFARER INFORMATION

Surname: Given Name (s):

Date of Birth (dd/mm/yyyy): Nationality: Gender:
ID Document no: Male/Female
Capacity that the seafarer will serve onboard serve in:
Deck: Engineer GMDSS Rating Catering Other
DECLARATION OF APPROVED** MEDICAL PRACTITIONER

I confirm that identification documents were checked: YES / NO

Does the seafarers hearing meet medical standards*? YES / NO

Is unaided hearing satisfactory*? YES / NO

Vision acuity meets medical standards*? YES / NO

Colour vision meets standard*? YES / NO

Date of last colour vision test? (dd/mm/yyyy) ______________

Is the seafarer fit for lookout duties: YES/NO/Not applicable

Is the seafarer free from any medical condition likely to be aggravated by service at sea or render the seafarer unfit for
such service or to endanger the health of other persons on board? YES/NO

Is the seafarer fit for service? YES/ NO

Are there any limitations or restrictions on fitness? If so specify the limitation.

B103 Rev.03 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 19 of 22

Contact: [email protected]
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 Bahamas Maritime Authority

I hereby confirm that the medical examination has been carried out in accordance with the ILO/IMO Guidelines on the
Medical Examinations of Seafarers and the national guidelines of the authorising Administration.

Name of Approved** Medical Practitioner:_________________________________________

Signature of Approved** Medical Practitioner:_______________________________________

Date of Examination (dd/mm/yyyy) : ______________ Stamp/Seal

Expiry date of certificate (dd/mm/yyyy): ____________

SEAFARER ACKNOWLEDGEMENT

I Name of seafarer confirm that I have been informed of the content of certificate and the right to get a review***.

Signature: _____________________________ Date: (dd/mm/yyyy)_____________

* For persons who are assigned shipboard safety, security or environmental protection duties, the medical standards
referenced on the certificate are the standards as specified in STCW Regulation I/9 and any other standards as specified
by the authorizing Administration. For any other persons serving onboard, the medical standards shall be as specified by
ILO and the authorizing Administration.

** The Medical Practitioner shall be approved by the national Administration, after inspection of medical
facilities/recordkeeping, to carry out STCW/ILO medical examination.

*** The review shall be carried out by a body/Medical Practitioner authorized by national Administration and this
information should be made available to the seafarer

B103 Rev.03 SEAFARER MEDICAL EXAMINATION AND CERTIFICATE Page 20 of 22

Contact: [email protected]
+44 20 7562 1300
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