:

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c: 157978
lnssrssMENT oF FtrNEss /+t 't'7t
hORE WORKERS REV. 3
I

i SECTION 2 . FOR UsE BY EXAMINING DOCTOR

VISION Near COLOUR BLOOD

HEIGHT Wl:IGHT BMI BLOOD PULSE lE'tu'l- GROUP
(Ko/m2) PRESSURE Corrected VISION
(cm/inch) (Kil rs/lbs)
,fr w.8" ltu Uncorrected Tnlrt "Zsrlt
WbL l*lt-e-
tbh 24 @z-
N A DESCRIPTION MEDICAL EXAMINATION - Detail of findings
t/ 1. Eye;&Pupils
t/ 2. Ear,Nose/Throat

t/ 3.
4.
Tee.h & Gum
Mor th
i"*t*- 7"hJ U 'rr
t/ 5. Res'riratory

6. Car liovascular SYstem

7, Abcomen

B. Henial Orifices
9. Extr:mities

GA"" Lft y'or*

t/ 1 0 Mur;culo-skeletal

r' 11. Ski r & Varicose Veins

'12. Nerrrological

;/ 1 3. Bre asts

14. Anrs & Rectum

15. G€ nito-Urinary Systems

16. Otl ers

A TEST INVESTIGATION FINDINGS

N

1. Co nplete Blood Count

2, BUSE
3. Se um Creatinine
4. Fa iting Serum Lipid

5 Fa;ting Blood Sugar

6. Uriralysis
7, Urile Drugs
r, Amphetamine
r. BenzodiazePines

t/
;.
1,
;.
B Ar-diometry
Cannabis
MDMA
Opiates

il4bl 9ql)lrt
|.r^*
9, ClestX-ray

10. E(rG (40 years and above or clinically

inr icated

11 . 56 irometry (if clinically indicated)

12. Oirers

Medical Fitness , \ssessment

Fit for specific olfshore work (Catering Crew/ Crane Operators/ Users of Breathing Apparatus)
please delete as approPriate

Fit for offshore v,ork with restriction

PMU AME Signatt re:

stamp: MBBS (MAL)' Mlvted'

occ' Med'
to requestin g employer or employee as appropriate. The copy to be retained by PMU AME
ro be compretetind:U.U"ggBtfgry.ff hfieH."d