Beverley & Molescroft Surgery Offshore Medicals

Beverley & Molescroft Surgery UKOOA Offshore Medicals MEDICAL QUESTIONNAIRE / EXAMINATION FORM

Personal Details Name: D.o.B: Address: Tel No:01 Marital Status Single GP Name & Address: Offshore Job Title: Date last offshore medical:First assessment Date of last survival course: First assessment Fireteam member: No

Social/Occupational History Yes/No Comments 1. Do you smoke? How many per day? No 2. If ex-smoker when did you stop? 3. Average weekly alcohol consumption Nil units/week 4. Have you been exposed to any known occupational hazard such as noise, radiation, No dusts, asbestos, chemicals or lead? 5. Have you suffered an industrial injury? If so, No please give details: 6. Have you ever developed any medical No condition connected with your occupation? 7. Have you had any previous audiometric Normal No screening? Comment: 8. Have you had previous lung function Normal No screening? Was this normal? Comment: 9. Have you ever been rejected from No employment on medical grounds? 10. Have you received compensation, or is there No any industrial claim pending? 11. Have you ever been medivaced from an No offshore installation?

Examining Physician’s Comments: GENERAL MEDICAL QUESTIONNAIRE

DO YOU HAVE OR HAVE YOU BEEN DIAGNOSED AS SUFFERING FROM ANY OF THE FOLLOWING: Yes/No Comment Chest pain / heart disease/high blood No pressure/stroke. Asthma / Epilepsy / Diabetes/TB No Peptic ulcer disease No Kidney disease (eg. stones) No Psychiatric disease inc Phobias (fear No of flying/heights) Cancer No

DO ANY OF YOUR IMMEDIATE FAMILY (PARENTS / BROTHERS / SISTERS ) HAVE A HISTORY OF ANY OF THE ABOVE CONDITIONS? PLEASE SPECIFY:

DO YOU HAVE OR HAVE YOU HAD ANY SIGNIFICANT OR RECURRENT PROBLEMS WITH THE FOLLOWING: Yes/No Comment Do you have any current illness? No Are you receiving any medication No including vitamins etc. at present? Do you have any allergies? No Surgical operations? No Hospitalisation No Have you attended a dentist in the No last year? Are you undergoing dental No treatment? Bachache / joint or muscular pain No Hernia/Rupture No Visual impairment No Perforated eardrum /ear discharge No Recurrent indigestion No Jaundice / hepatitis / gallbladder No Change in bowel habit / diarrhea No Blood in stool/piles/haemorrhoids No Shortness of breath / coughing blood No Recurrent bronchitis/pneumonia No Blood in urine / kidney No complications / stones Headaches / migraine / dizziness No Tropical illnesses/Venereal No diseases /HIV History of alcohol / drug abuse No VACCINATIONS Vaccination Date Vaccination Date Vaccination Date Vaccination Date Vaccination Date Vaccination Date Vaccination Date Vaccination Date

FOR FEMALES ONLY – HAVE YOU EVER HAD? Yes/No Comment An abnormal smear / breast disease? No Gynaecological problems? No Complications of pregnancy? No Please give date of LMP

Examining Physician’s Comments:

“I DECLARE THE ABOVE TO BE TRUE TO THE BEST OF MY KNOWLEDGE. I AGREE THAT THE RESULT OF MY MEDICAL EXAMINATION, INCLUDING APPROPRIATE INVESTIGATIONS CARRIED OUT IN ORDER TO ESTABLISH MY MEDICAL FITNESS MAY BE REVEALED TO A COMPANY MEDICAL OFFICER IF REQUIRED. I ACCEPT THE TRANSFER OF MY MEDICAL FILES TO OTHER DOCTORS WORKING FOR THE COMPANY IN WHICH I GAIN EMPLOYMENT.”

NON DECLARATION OF SIGNIFICANT MEDICAL PROBLEMS MAY RESULT IN TERMINATION OF EMPLOYMENT.

SIGNATURE OF UKOOA APPLICANT……………………………………………………