How to write a Medical Examination Report? Download this Medical Examination Report template that will perfectly suit your needs.
Our collection of online health templates aims to make life easier for you. Our site is updated every day with new health and healthcare templates. By providing you this health Medical Examination Report template, we hope you can save precious time, cost and efforts and it will help you to reach the next level of success in your life, studies or work!
CHROMAGEN LENSES MUST NOT BE WORN Have you ever been declared unfit for duty at sea Yes No If yes, state when, for how long and for what reason Rating-Deck (Rating - Navigational Watch / Able Seafarer Deck) Rating-Engineering (Rating - Engine Room Watch / Able Seafarer - Engine ) Catering (Marine Cook) Other (specify) Denotes Hepatitis A arrangements apply Has your Certificate of Medical Fitness ever been restricted or cancelled or have you ever been declared unfit Yes No Personal history Are you in good health now Yes No Do you drink alcohol Yes No Yes No Yes No If yes, give details If yes, how much and how often Do you smoke tobacco If no, have you smoked in the past Yes No If yes, give details Have you been absent from work due to sickness or injury for more than 14 consecutive days over past two years Yes Have you ever been signed off as sick or repatriated from a ship No If yes, give details AMSA 232 (6/16) 1 of 4 Have you now, or have you previously had any of the following: • • • • • Anxiety or depression Migraine or persistent headaches Epillepsy or fits Poliomyelitis or other paralysis Attack of unconsciousness or weakness, dizziness or turns Yes • • • • • • • • High blood pressure Disease of the heart, arteries or blood vessels Operation on the heart Anaemia or any other disease of the blood Swelling of the ankles Palpitations Varicose veins or abnormal bleeding Rheumatic fever • • • • • • • • • Disease of the liver (including jaundice or hepatitis) Disease or ulcer of the stomach or duodenum Recurrent abdominal pain/persistent indigestion Appendicitis Gallbladder disease Disease of the bowels Haemorrhoids (piles) Hernia (rupture) Recent change in weight • • • • • • • Asthma Bronchitis or emphysema Tuberculosis Persistent breathlessness Persistent cough Collapsed lung Other lung disease/abnormal x-ray • • • • • Infection of bladder Kidney disease or kidney stone Difficulty in passing urine Any abnormality of the urine Sexually transmitted disease Yes Y
This Medical Examination Report is intuitive, ready-to-use and structured in a smart way. Try it now and let this Medical Examination Report sample inspire you.
We certainly encourage you to download this Medical Examination Report now and use it to your advantage!
Also interested in other health and healthcare templates? AllBusinessTemplates is the most elaborate platform for downloading health templates and is updated every day with new health and healthcare related templates! Just search via our search bar or browse through our thousands of free and premium health forms and templates, contract, documents, letters, which are used by professionals in the healthcare industry. For example health care directive, mental health treatment plan, health management report, allergy log, healthy weekly meal plans, sick leave letter, health evaluation form, and much more...