This Seafarer Medical Certificate complies with STCW 1/9,

IMO/ ILO-73 , MLC 2006 and Bahamian and Maltese Medical

Standards or as approved by Countries with a Reciprocal
Recognition Agreement, Guidance for conducting Medical
Fitness Examination for Seafarers

PRE-EMPLOYMENT
MEDICAL EXAM FORM B

CREW MEMBER INFORMATION

Family Name:

Given Name:

Gender:

Male
Seamans Book No.:

Crew I.D. No.:

ID Confirmed?

Exam Date:

Yes
City of Residence:

Country of Residence:

Birth Date (day/month/year):

Crew Position:

Passport No.:

Nationality:

Female

No

Vessel:

Type of Ship:

Trade Area:

Container

Tanker

Passenger

Fishing

Coastal

Tropical

Worldwide

GENERAL
Height
Urinalysis

Weight

Temp

Glucose

Protein

Respiratory Rate

Pulse Rate

B/P Systolic

Rhythm

B/P Diastolic

Body Mass Index (BMI)

VISION
Visual Acuity
Vision

Color Vision

Unaided
Aided
Right eye Left eye Binocular Right eye Left eye Binocular

Distant
Near

Ishihara
Snellen
Normal
Defective

PURE-TONE AUDIOMETER (THRESHOLD VALUES IN DB)

EAR
Right

500hz

1000hz

2000hz

3000hz

4000hz

Vision Adequate for Position Per

Flag State Requirements?

Field Vision

Bostrom Kugelberg
R = WNL ___
Passed
Not Passed L = WNL ___
Doubtful
Not Tested

Yes

No

SPEECH AND WHISPER TEST (METERS)

6000hz

8000hz

Whisper Test: Yes

No
If ABNORMAL perform Audiogram
Information on the use of hearing protection provided?
Yes
No

Any subjective signs of impaired hearing or dizziness?

Left

Yes

No

CHEST X-RAY
Not performed

Normal

Abnormal

Results:

Performed on (day/month/year):

VACCINATIONS
Name of
Vaccination
Diphteria
Tetanus
Typhoid
Pertussis

REQUIRED TESTS

Date of last
vaccination

Name of
Vaccination
Polio
Varicella
Hepatitis A & B

Date of last
vaccination

MMR Mandatory
show proof of vaccine

Yellow fever

Chest X-ray (attach report)

VDRL/RPR/FTA (use one)
CBC (complete blood count)
Routine Urinalysis

Attach ALL LAB TESTS to Original

All results must be in ENGLISH
Pregnancy Test (all Females)
O&P (Food and Beverage Positions)
Hepatits A IgM, HBsAg and Anti HCV

And
Lipid Panel total
Chol, HDL, LDL,
Triglycerides

Urine Drug Test (Benzodiazepines,

Results requiring investigation

Blood Chemistry
BUN, Creatinine,
Glucose, ALT,
AST, Uric Acid

Amphetamines, THC, Opiates, Cocaine)

EKG
(required
ONLY if
theres a
history of
High Blood
Pressure)

PHYSICAL EXAM
Normal

HEENT
Mouth / Teeth
Tonsils
Pharynx
Ears/Tympanic Membrane
Eyes/Eye Movement/Pupils

Head
Nose
EMOTIONAL / PSYCHIATRIC
Status
Normal
HEART
Rhythm
Murmurs
SKIN
Normal

THORAX
LUNGS
Percussion
Auscultation
EXTREMITIES
Varicose veins
Edema
Scars
Discoloration
Deformities
NEURO
Abnormal
Motor
Sensory
Reflexes
Abnormal PULSES
Abnormal

Normal Abnormal

ABDOMEN
Shape
Tenderness
Normal Abnormal
Masses
Scars
Hernia

Normal

Testicles
PELVIC
Normal
Normal Abnormal
Status
Normal
BREASTS
Tenderness
Masses
Normal Abnormal

RCL Pre-employment Medical Examination Form B Revised 2015-03.docx

Abnormal

RECTAL

Normal

Abnormal

Normal

Abnormal

Hemorrhoids
Prostate
Fistula
NECK

Abnormal
Abnormal

Nodes
Motion
Thyroid
Lungs / Chest
Vascular pulse
G-U System
Upper & Lower Extremities
Spine (C/S, T/S and L/S)
General Appearance

ORIGINAL give to Employee to take to Ship Medical

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RANGE OF MOTION
Normal
CERVICAL
Forward flex
Extension
Lateral flexion
Rotation
Scars
HIP
Flexion
Extension
Abduction
Adduction
Int.rotation
Ext.rotation
FINGERS
Flexion
Extension

Abnormal ELBOW

Normal

Abnormal LUMBAR

Retained flex
Extension
Pronation
Supination
Scars
FEET
Inspection
Arch status
Deformities
ANKLE
Dorsal flex
Plantar flex
Inversion
Eversion
Scars

Normal

Abnormal

Forward flex
Extension
Lat. Flex
Rotation
Slr (sitting)
Slr (supine)
Scars
SHOULDER
Forward elev.
Backward elev.
Abduction
Adduction
Int. Rotation
Ext. Rotation
Scars

Normal
WRIST
Pronation
Supination
Dorsiflexion
Planer flexion
Abduct
Adduct
KNEE
Retained flex
Extension
Scars

Abnormal

Previous psychiatric and/or back conditions requires letter from specialist

Applicant questioned regarding current or previous psychiatric condition/diagnosis?
If applicants answer is Yes please describe below

Yes

No.

Applicant questioned regarding current or previous back/lumbar condition/diagnosis?

If applicants answer is Yes please describe below

Yes

No

ABNORMALITIES FROM PHYSICAL EXAMINATION

ASSESSMENT OF FITNESS FOR SERVICE AT SEA

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

FIT FOR DUTY : (crew member is not

believed to be suffering from any sickness or
physical or mental ailment making him unfit for
service or which may endanger the health of the
other persons onboard.)

DECK SERVICE

NOT FIT FOR DUTY for the following reason(s):

ENGINE SERVICE

FIT AFTER DEFECT CORRECTED (Describe):

CATERING SERVICE (F&B)

OTHER SERVICES

Fit
Unfit

Without Restrictions
With Restrictions
Describe restrictions (e.g. specific position, type of ship, trade area):

Are they able to perform all activities of their job?

SIGNATURE

MEDICAL EXAMINER NAME (please print)

Yes

No

Forms without Physician contact information are not acceptable

MEDICAL EXAMINER SIGNATURE

RCL Pre-employment Medical Examination Form B Revised 2015-03.docx

DATE

ADDRESS

ORIGINAL give to Employee to take to Ship Medical

PHONE NUMBER

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