“BIENNIAL NATIONAL MEDICAL REPORT”

(all examinations are in accordance with STCW 95 / MLC 2006 / ILO-IMO GL 2013)
REPORT OF MEDICAL EXAMINATION OF SEAFARER BY THE APPROVED MEDICAL PRACTITIONER
(Approved by General Directorate of Shipping Government of Panama)

Dr. ________________________
(the approved Medical Practitioner)

Full Name M F

Date of Birth: Home Address

Nationality Passport n.°

Type of Vessel Trade Area

Department Duty (see below)

I. “Medical History”
Have you ever had any of the following conditions? Yes No Have you ever had any of the following conditions? Yes No

1. Severe headaches 13. High/Low blood pressure/Heart disease

2. Head Injury/Concussion/Loss of Memory 14. Asthmas/Bronchitis/Tuberculosis

3. Fainting/Seizures/Epilepsy/Balance problems 15. Diabetes/Thyroid Problem

4. Eyes/Vision Problems (Glasses, etc.) 16. Allergy/Skin disease

5. Hearing Impairment/Tinnitus 17. Infection/Contagious Disease

6. Ear/Nose/Throat problems 18. Major/Minor surgery operation

7. Stomach/Bowel/Digestive disorders 19. Hernias/Hydrocele/Appendicitis

8. Gall stones/Kidney disorders 20. Fracture/dislocation /Injury/Amputation

9. Jaundice/Liver Disease 21. Back or joint problems/Restricted mobility

10. Piles/Varicose Veins 22. Addiction to Alcohol/Drugs/Tobacco

11. Blood Disorder 23. Nervous/Mental disease/Sleep disorder

12. Female Disorder/Pregnancy 24. Malignant disease (Cancer)

If “yes” to any of the above questions, please give details:

Additional questions Yes No Additional questions Yes No

Have you ever been hospitalized, signed off as sick or Are you aware that you have any medical
repatriated from a ship ? problems, diseases or illnesses ?
Do you feel healthy and fit to perform the
Have you ever been declared unfit for sea duty ?
duties of your designated position/occupation?

Has your medical certificate even been restricted/revoked ? Are you allergic to any medication ?

Are you taking any non-prescription or prescription medications ?

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

Comments:

I hereby certify that the personal declaration above is a true statement to the best of my knowledge.
I hereby authorize/not authorize the release of all my previous medical records from any health professionals, health institutions and public
authorities to Dr _____________________________________ (the approved Medical Practitioner).

Signature of examinee: ______________________________________ Date _____ / _____ / ___________

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 “BIENNIAL NATIONAL MEDICAL REPORT”
(all examinations are in accordance with STCW 95 / MLC 2006 / ILO-IMO GL 2013)
REPORT OF MEDICAL EXAMINATION OF SEAFARER BY THE APPROVED MEDICAL PRACTITIONER
(Approved by General Directorate of Shipping Government of Panama)

Dr. ________________________
(the approved Medical Practitioner)

II. “Medical Examination”

Height cm. Weight kg. Pulse rate /min Blood Pressure mmHg
1. Head & Neck Normal Abnormal 9. Respiratory system Normal Abnormal
2. Eyes movement/Pupils Normal Abnormal 10. Cardiovascular system Normal Abnormal
3. Ears (tympanic
Normal Abnormal 11. Per Abdomen Normal Abnormal
membrane)/Nose/Throat
4. Teeth/Oral/Cavity Normal Abnormal 12. Genito-urinary system Normal Abnormal
5. Musculo-Skeletal system Normal Abnormal 13. Mental Capacity Normal Abnormal
6. Nervous system Normal Abnormal 14. Hernia/hydrocele Normal Abnormal
7. Reflexes Normal Abnormal 15. Varicose Veins Normal Abnormal
8. Skin Normal Abnormal 16. Fissure/Fistula/Piles Normal Abnormal
Comments/Notes:

SIGHT
Use of glasses or contact lenses: Yes/No
(if yes, specify which type and for what purpose): ____________________________________________________________________
Distant Near
Visual Acuity
Unaided Aided Unaided Aided
Right eye
Left eye
Binocular
Visual Field
Ishihara Test Normal Defective Normal Defective
(Confrontation tests)

Only for look-out duties

Low-contrast
Farnsworth Test Normal Defective Normal Defective
vision test

HEARING
Use of hearing aid: Yes/No
(if yes, specify which type and for what purpose): ____________________________________________________________________

Audiometry (see report attached) Threshold values 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz
Right Ear <25 dB
Left Ear <25 dB

Speech and Whisper Test (3 metres) Normal Defective

Notes:

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 “BIENNIAL NATIONAL MEDICAL REPORT”
(all examinations are in accordance with STCW 95 / MLC 2006 / ILO-IMO GL 2013)
REPORT OF MEDICAL EXAMINATION OF SEAFARER BY THE APPROVED MEDICAL PRACTITIONER
(Approved by General Directorate of Shipping Government of Panama)

Dr. ________________________
(the approved Medical Practitioner)

III. “Laboratory Test Results”

Complete Blood Count Urinalysis

g/dl
Hemoglobin Glucose

Total WBC count /mmc Protein

Neu % Lymp % Eos % Ba % Mo %
Blood
/mmc
Platelets Other:

Blood Group

mg/dl U/L
Blood sugar AST (SGOT)
mg/dl U/L
S-Cholesterol ALT (SGPT)
mg/dl U/L
S-Triglycerides Gamma-GT

Azotemia mg/dl
Other:

Creatinine mg/dl

HBs Ag Negative Positive Note:

(Hepatitis B Virus)
HCV Negative Positive Note:
(Hepatitis C Virus)
Pulmonary TB screening test Negative Positive Note:
VDRL Negative Positive Note:
(Syphilide)

CHEST X-Ray Normal Abnormal (see report attached)

ECG (Electrocardiogram) Normal Abnormal (see report attached)

SPIROMETRY Normal Abnormal (see report attached)

Other:

Comments:

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 “BIENNIAL NATIONAL MEDICAL REPORT”
(all examinations are in accordance with STCW 95 / MLC 2006 / ILO-IMO GL 2013)
REPORT OF MEDICAL EXAMINATION OF SEAFARER BY THE APPROVED MEDICAL PRACTITIONER
(Approved by General Directorate of Shipping Government of Panama)

Dr. ________________________
(the approved Medical Practitioner)

IV. “History”
Occupational History
Duty:
(risk factors, protective
equipments …)

Family History
Father:
Mather:
Partner:
Children:
Collateral

Physiological history
Appetite:
Digestion:
Bowel movements:
Urination/diuresis:
Allergy:
Vaccination:

Lifestyle
Tobacco:
Alcohol:
Coffee:
Sport:

Comments/Notes:

V. “Results of Medical Examination”

Medical Practitioner’s Final Comment:

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 “BIENNIAL NATIONAL MEDICAL REPORT”
(all examinations are in accordance with STCW 95 / MLC 2006 / ILO-IMO GL 2013)
REPORT OF MEDICAL EXAMINATION OF SEAFARER BY THE APPROVED MEDICAL PRACTITIONER
(Approved by General Directorate of Shipping Government of Panama)

Dr. ________________________
(the approved Medical Practitioner)

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 Not applicable
Visual aid required No Yes

Deck Service Engine Service Catering Service Other Service

Fit
Unfit
With restrictions No Yes
If yes, describe restrictions (e.g., specific position, type of ship, trade area):

Date of medical certificate issued (day/month/year) / /

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

Number of medical certificate

Signature of medical practitioner:

Medical practitioner information: Name:

License N°:

Address:

Panama Authorization:

Crewmember Signature Recruiting Agent Stamp Doctor’s Signature & Stamp

(I confirm that all Doctor’s comment has
been discussed & acknowledged)

According to MLC 2006, may be possible for the seafarer that have been refused a medical certificate or have had a limitation
imposed on his/her ability to work to request a further examination by competent authority, in line with procedures for appeal.