A ""1 Isex: Medical Certificate For Personnel Service On Board
A ""1 Isex: Medical Certificate For Personnel Service On Board
A ""1 Isex: Medical Certificate For Personnel Service On Board
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A
WITHOUT GLASSES WITH GLASSES BOOK
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I
RIGHT EYE -- LANTERN RIGHTEAR
-- --
®--
YELLOW RED
LEFT EYE U_b -- GREEN
-- BLUE
-- LEFT EAR
Contrmation that identitlc;atlon documents were checked at Iha point of examlnatlon: YES 0 NO O
I
Healing meets 1he slandards In STCW Code, Section A-119? YES 0 NO D NOT APUCABLE D
Unaided !loofio!I sausractor/1 YES 121 NO 0
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I
Visual acuity meets sl3ndards In STCW Code, Section A-119? YES NO O
Coloor vision meets standards In STCW Code, Section A-1/9? YES ,.J2{ NOD
(the vlsual 1esl It IS required every six years)
Dale of the last colour vision test: (Day/Monlh/Year) �0
l O', l :U,I�
,,
Are otasses or contact lenses necessary lo meet the re<iuired vision standards? YES DI' NO n �
Able for walchkeeping? YES E1 NO O
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Is applicant taking any non-preSC/lpUon or prescription medicaUons? YES O NO
Is th& seafarer free from any medical condiUon 1111ety aggravated by service al sea or to render the seafarers unfit for such service or lo
endanger the heal1h or other persons on board? YES NO O
Hereby I declare 111311 am in knOwtedge of Ille contents of the Physical Examination.
3!£�Signature of Applicant
TAl!APE f.11f MA!leHAEL..
Name of Applicant
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Dal&
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<Bi)/
SHE) IS FOUND TO �I NOT FIT) FOR DUTY AS A (MASTER f DECK OFFCIER I
f
CIRCLE APPROPIATE CHOICE:
ENGINEERING OFFICER I RADIO OPERATOR I RATING) (WITH YI WITH THE FOLLOWING) RESmlCTIONS: i
.
NAME AND DEGREE or PHYstclAN:
ADDRESS: �lJO 'SliOt--lEi,
Ar. HA 121 A
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f·D. MOJ...I
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NAME OF PHYSICIAN'S CERTIFICATING AUTHORITY: //,._((,·/ ��.\\.
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DATE OF ISSUE PHYSICIAN'S CERTIF.!CATE:
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StGNATURE OF PHYSICIAN: 'STAMP r DATE: i� Ml\-� ?-0{$
� Y,lllCIAN:
Test: Result:
On the basis of the examinee's personal declaration, my clinical examination and the diagnostic
test results recorded above, I declare the examinee medically:
Name of medical practitioner (typed or printed): Jlr· tf f\fi-1 A f · t), f-'ti,µ f+f,�
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Address of medical practitioner: 12�1.JD � 111) 1-l b -:)L,. si1 SAP ul-( �A;:)MJ b \1 Ai.J H1!,0 - l-(Gt'100
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Authorized by: Panama Maritime
F-ALM-011
Rev. 03
Page 4 de 4
Date: 13/03/2013.
.·.
MEDICAL EXAMINATION
Sight
Use of glasses or contact lenses: Yes@(if yes, specify which type and for what purpose)
Normal Whisper
SOOHz 1,000 Hz 2,000 Hz 3,000Hz
I Right ear Right ear
I Left ear Left ear
Clinical data
F-ALM-011
Rev. 03
Page 3 de4
Date: 13/03/2013.
FORMAT FOR RECORDING MEDICAL EXAMINATIOS
OF SEAFARERS
Name (last, first, middle):
If any of the above questions were answered 11yes111 please give details
F-ALM-011
Rev. 03
Page 1 de 4
Date: 13/03/2013.
Additional questions YES NO
35. Have you ever been signed off as sick or repatriated from a ship? �
36. Have you ever been hospitalized? IV
37. Have you ever been declared unfit for sea duty? I/
38. Has your medical certificate ever been restricted or revoked? IV
39. Are you aware that you have any medical problems, diseases or illness? v
40. Do you feel healthy and fit to perform the duties of your designed position/occupation? � -
41. Are you allergic to any medications? t-1
Comments:
If yes, please list the medications taken and the purpose(s) and dosage(s).
I hereby certify that the person I declaration above is a true statement to the best of my knowledge.
Date (day/month/yei
r : a P
I 05/ �(�
Witnessed by:
---=!�"-------------------------�
Name: (typed or printed): E,ll,l, A . Sl.Jttl /11:-1 foU OJ • �- ¥- �f
I hereby authorize the release of all my previous medical records from any health professionals,
health, institutions and public authorities to Dr. MAit II- p. D. t'lC>f.tlAGA (the approved
medical practitioner).
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Signature of examinee: ---t-�
--�---------------------
-
Date (day/month/year):
�8 ,Oij
(Signature):--�
Witnessed by: ..........�'-"---------------------
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Date and contact details for previous medical examination (if known):
-----------
F-ALM-011
Rev.03
Page 2 de 4
Date: 13/03/2013.