MAG 4 Seafarer Medical Examination,Simfer(CH)

Personal Information
1. Employee First Name
2. Employee Surname
3. Middle name(s)
4. Date of birth(DD/MM/YYYY)
5. Gender
6. Employer/Company Name
7. Age
8. Passport Number (required in the event of evacuation)
9. Nationality
10. Work phone number
11. Home phone number
12. Mobile phone number
13. Personal email
14. Work email
15. Worksite name
16. Worksite / Location (assignment country)
17. Employee Number
18. Job Role
19. Job Title/Position
20. Rotation Schedule (rotating assignees)
21. Type of Ship (e.g. container, tanker, passenger)
22. Routine and emergency duties ( if know)
23. Relocating to the assignment country?
24. Home language
25. Branch/ division
26. Personal Health Insurance
27. Personal Health Insurance Number
28. Surname of emergency contact
29. Name of emergency contact
30. Relationship with emergency contact
Personal Medical History
Sickness Record
31. Have you had any periods of illness in the past 2 years? (excluding colds and flu)
32. If "Yes" please complete the following:
Please state periods of illness. (including the number of days off per episode)
Please state the reason for absence. ( type of illness) 
33.
Occupational History
Please list the previous four role titles.From (YYYY). To (YYYY). Company Name.
34. Occupational Hazards
  • Yes
  • No
Will you be required to perform emergency response team duties?
Will you be required to wear a respirator?
Will you be working at heights?
Will you be working in confined spaces?
Noise
Dust (especially silica dust) and Asbestos:
Toxic chemicals
Heat exhaustion or heat stroke
35. Have you ever received any compensation related to work-related injury?
36. Select the anticipated most frequent tasks to be performed
37. Audio/ Hearing Questionnaire 
  • Yes
  • No
Have you ever worked in noisy environment?
Do you wear hearing aids?
Do any of your family members have hearing problems?
Do you have irritating noises in your head or ears (tinnitus)?
Do you have problems such as excessive wax, ear infections or blockages?
Do you partake in noisy activities such as motorbike/ car racing, shooting etc.?
38. Do you wear ear protection at work?
39. Have you ever had: Meningitis, Mumps, Measles, Scarlet Fever, Rheumatic Fever or TB?
40. TB Questionnaire
  • Yes
  • No
The cough lasting longer than 2 weeks?
Haemoptysis (coughing up blood)?
Fever /Chills /Temperatures?
Drenching night sweats for no reason?
Fatigue /Weakness?
Anorexia (loss of appetite)?
Unexplained weight loss ＞5kg /11lbs. per month?
Have you been in contact with a person known to have TB?
Received BCG vaccination?
41. Previous TB screening (if "Yes", please supply results)?
42. If you have answered "Yes", please detail the approximate date, and if ongoing or resolved:
43. Epworth Sleepiness Questionnaire
The information below is utilised to assess your propensity to fall asleep during the day.
Please tick the appropriate box.
0=No chance of dozing
1=Slight chance of dozing
2=Moderate chance of dozing
3=High chance of dozing
  • 0
  • 1
  • 2
  • 3
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g., a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
44.
Examinee's personal declaration (Assistance should be offered by medical staff)
Have you ever had any of the following conditions?
  • Yes
  • No
Eye/ vision problem
High blood pressure
Heart/ vascular disease
Heart surgery
Varicose veins/ piles
Asthma/ bronchitis
Blood disorder
Diabetes
Digestive disorder
Kidney problem
Skin problem
Allergies
Infectious/ contagious diseases
Hernia
Genital disorder
Pregnancy
Sleep problem
Do you smoke, use alcohol or drugs?
Operation/ surgery
Epilepsy/ seizures
Dizziness/ fainting
Loss of consciousness
Psychiatric problems
Depression
Attempted suicide
Loss of memory
Balance problem
Severe headaches
Ear( hearing, tinnitus)/ nose/ throat problem
Restricted mobility
Back or joint problem
Amputation
Fractures/ dislocations
45. Additional questions
  • Yes
  • No
Have you ever been signed off as sick or repatriated from a ship?
Have you ever been hospitalized?
Have you ever been declared unfit for sea duty?
Has your medical certificate even been restricted or revoked?
Are you aware that you have any medical problems, disease or illnesses?
Do you feel healthy and fit to perform the duties of your designated position/ occupation?
46. Are you allergic to any medication?
47.
Colour Vision
If yes to colour vision, please specify which colours:
48. Diabetes( only complete if you are diabetic)
  • Yes
  • No
Do you use insulin?
Do you test your glucose levels?
Have you ever experienced low blood sugar?
Is your HbA1C level tested twice a year (3 monthly blood tests)?
49. Are you able to recall  your most recent HbA1C Level?
50. Other endocrinological disorders
  • Yes
  • No
Thyroid gland disorders
Adrenal gland disorders
Pituitary gland disorders
Parathyroid disorders
Other
51. Surgical History
Please list any previous surgeries
52. Have you been advised to undergo surgery within the next three months?
53. Allergies
  • Yes
  • No
Food
Medication
Fabric/ Clothing
Chemicals
Do you carry an Adrenalin/ EpiPen injection?
Unexplained weight loss﹥5Kg/ 11 lbs.per month?
Previous hospitalization for allergies?
54. Dental Conditions
  • Yes
  • No
Do you currently have a toothache?
Do you require a dental implant/ crown?
55. Emotional Wellbeing
  • Yes
  • No
Sought counselling or care with a medical professional in the past?
Depression
Bipolar disorder (manic depression)
Schizophrenia
Post-traumatic stress disorder
Electroconvulsive/ shock therapy
Attention deficit disorder
Attention deficit hyperactivity disorder
Anxiety
Panic attacks
Work-related stress
56. Psychological Questionnaire
Over the past two weeks, have you ever been bothered by any of the following problems?
  • Not at all
  • Several days
  • More than half the days
  • Nearly everydays
Little interest or pleasure in doing things?
Feeling down,depressed or hopeless.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling about yourself- or that you are a failure or have let yourself down or your family down
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have noticed. Or the opposite- being fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead or hurting yourself in some way.
57. Other-Childhood diseases/ phobias etc.
  • Yes
  • No
Chickenpox
Measles
Mumps
Polio
Rubella/ German Measles
Rheumatic fever
Tropical/ infectious diseases
Tumor/ cancer or malignancy 
Claustrophobia( Fear of confined spaces)
Fear of heights
58. Medication Use
Please list names and dosages of all medication taken during the last 4 weeks( including over-the-counter medication, asthma inhalers, herbal supplements and prescription medication). Please also list any cold & flu medication and pain medication.
Name of drug, reason of use, strength& frequency.
59.
If you are taking Warfarin( Coumadin) please complete the following questions:
Can you recall when your last INR level was checked and what INR level was? 
60. Do you own a self-testing device to monitor your INR levels?
61. Have you ever experienced any side effects from anti-malarial medication? If "Yes", please specify:
62.
Personal/ Lifestyle Habits
Tobacco Usage
Do you smoke?
63.
If you are a smoker/ former smoker please complete the section below.
Conventional cigarettes smoked per day.
64. Have you used any other types of tobacco products?
  • Yes
  • No
E-cigarttle
Smoking pipe
Chewing tobacco
65. Any other form of tobacco consumption, please provide details with frequency:
66. Alcohol Consumption 
  • Yes
  • No
Have you ever felt you should cut down on your drinking?
Has a relative/ friend/ doctor/ health worker ever been concerned about your drinking or suggested you cut down?
During the last year, have you ever felt guilt/ remorse after drinking?
During the last year have you ever needed a drink in the morning to get yourself going during the heavy drinking session?
Have you ever received treatment/ rehabilitation for alcoholism/ alcohol abuse?
67. Number of alcohol units per week(10g=1 can beer=1 glass wine=1 glass nip/ spirit)
68.
Substance Use
Do you currently use any substances/ street drugs?
69.
Have you received treatment/ rehabilitation for any substance abuse?
70. Exercise
Do you exercise regularly?
71.
Travel Questionnaire: If travelling outside your home country, please complete this section
If travelling by air to reach your worksite, how long is your anticipated flight?
72. Do you have a valid Yellow Fever certificate?
73. Do you have a valid visa for the country(ies) of assignment?
74. Are you fully vaccinated against COVID-19?
75.
If "Yes" name of the vaccine:
V1*= Vaccination( first dose)
V2*= Vaccination( second dose)
Medical Declaration and Record Release Form
76. I hereby certify that the personal declaration above is a true statement to the best of my knowledge.

Signature of examinee：______

Date (DD/MM/YYYY):______

Witnessed by(signature)：______

Name(typed or printed)：___

I hereby 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 (DD/MM/YYYY):______

Witnessed by(signature)：______

Name(typed or printed)：______

Date and contact details for previous medical examination( if known)：______
更多問卷 復制此問卷