PART I — To be completed by the physician. Record all abnormal findings on this medical examination record. Circle the correct answer as required.

Family name: First name(s):

Birth date: Sex: M/F

Ht: cm Wt:  kg  Identifying features:

General appearance:

VISION:	Distant	Distant with glasses	Near	Near with glasses	Normal visual fields	Normal Fundi
Right:					Yes/No	Yes/No
Left:					Yes/No	Yes/No
Both:					Yes/No	Yes/No

SKIN:

Rash? Yes/No  Infection? Yes/No  Parasites? Yes/No

Lymph glands normal? Yes/No  Breasts normal? Yes/No

RESP:

Any chest scars or deformity? Yes/No

Chest auscultation normal? Yes/No

Any adventitious sounds? Yes/No

Current chest X-ray normal? Yes/No/Not DoneFootnote ^*

CARDIOVASCULAR:

BP — / Pulse: — /min.

Peripheral pulses and circulation normal? Yes/No

Normal apex beat? Yes/No Normal heart sounds? Yes/No

Murmurs present? Yes/No ECG normal? Yes/No

Exercise tolerance test (eg. Ruffier test) normal? Yes/No

ABDOMEN:

Organomegaly? Yes/No Masses present? Yes/No

Herniae present? Yes/No

Genitourinary system normal? Yes/No Rectal normal? Yes/No

MUSCULO-SKELETAL:

Spine normal? Yes/No Limbs and joints normal? Yes/No

CENTRAL NERVOUS SYSTEM:

Power & tone of limbs normal? Yes/No

Normal sensation to pinprick? Yes/No

Light touch? Yes/No Temperature? Yes/No  Vibration? Yes/No

Proprioception normal? Yes/No

Cranial nerves normal? Yes/No

REFLEXES:	BJ	TJ	SJ	KJ	AJ	Abdo.	Planter	Clonus
Right:
Left:

Cerebellar function normal? Yes/No

Vestibular function normal? Yes/No

Rombergism present? Yes/No

Nystagmus present? Yes/No

LAB. INVESTIGATIONS:

Hb: g/dL HCT: Footnote ^*

Sickle cell trait absent? Yes/NoFootnote ^* (initial medical examination)

Blood group: BUN: Footnote ^* Creatinine: Footnote ^*

Other:

Urine pH: Urine free of:	albumin?	Yes/No
	sugar?	Yes/No
	protein?	Yes/No
	blood?	Yes/No

Comment on any abnormalities detected:

Is the candidate free from physical defect and disease? Yes/No

Has the candidate the physique for prolonged exertion? Yes/No

Is the candidate fit for work in all climates if inoculations are up-to-date? Yes/No

Is the candidate permanently unfit to dive? Yes/No

Is the candidate temporarily unfit to dive? Yes/No

Date for next examination:

Is the candidate fit to dive with restrictions? Yes/No

Specify:

Name and address of examining doctor:

Signed: Date:  Place:

PART II — To be completed by the candidate in ballpoint pen by the supervisor or ADS pilot. Circle the correct answer as required. If in doubt, ask the advice of the examining doctor

• (a) 

  Family name: First name(s): Birth date: S.I.N.: Provincial Health No.:
• (b) 

  Have you had an ADS pilot’s medical examination before? Yes/No

If yes, when? Where?

• (c) 

  Date and place of any X-ray examinations:

• (d) 

  Give details of vaccinations:

• (e) 

  Do you have, or have you ever had or been treated for, any of the following medical conditions?

  1.	Asthma	Yes/No
  2.	Hay fever or allergies	Yes/No
  3.	Allergy to drugs/medications	Yes/No
  4.	Pneumonia or pleurisy	Yes/No
  5.	Bronchitis or other lung diseases	Yes/No
  6.	Tuberculosis	Yes/No
  7.	Sinus trouble	Yes/No
  8.	Ear disease	Yes/No
  9.	High blood pressure	Yes/No
  10.	Rheumatic fever	Yes/No
  11.	Heart disease or murmur	Yes/No
  12.	Chest pain or palpitations	Yes/No
  13.	Bleeding tendency	Yes/No
  14.	Skin diseases	Yes/No
  15.	Diabetes	Yes/No
  16.	Tropical diseases	Yes/No
  17.	Fits, blackouts or epilepsy	Yes/No
  18.	Dizziness, loss of balance	Yes/No
  19.	Head injury or concussion	Yes/No
  20.	Stroke or paralysis	Yes/No
  21.	Severe headache or migraine	Yes/No
  22.	Nervous breakdown or mental illnesses	Yes/No
  23.	Eye disorders	Yes/No
  24.	Stomach/duodenal/peptic ulcer	Yes/No
  25.	Gall bladder disorder	Yes/No
  26.	Diarrhea or bowel disease	Yes/No
  27.	Jaundice or hepatitis	Yes/No
  28.	Kidney or bladder disease	Yes/No
  29.	Bone/joint disease or injury	Yes/No
  30.	Back injury or chronic back pain	Yes/No
  31.	Other serious illness or injury	Yes/No
  32.	Motion sickness	Yes/No
  33.	Varicose veins	Yes/No

Give details of any positive answers, including dates:

• (f) Give date and place of any hospital admissions or operations:

• (g) Have you been under medical treatment during the past year? Yes/No

If yes, for what?

• (h) Are you taking, or have you ever taken, any medicines or drugs? Yes/No

If yes, specify:

• (i) If you smoke, how many cigarettes do you smoke? /day

If you drink alcohol, how many glasses of wine /week, of beer /week and of spirits /week do you drink?

Have you ever suffered from any health problems related to mind-altering, “street” or addictive drugs? Yes/No

If yes, give details:

I (name) , of (address) , declare that all of the above information is true to the best of my knowledge and I give my permission for this information to be communicated to other doctors concerned with my well-being.

Signed: Date:  Place:

PART III — Physician’s Statement

Doctor’s Remarks:

Candidate’s logbook inspected? Yes/No

If “no”, state reason:

Signed: M.D.

Dated: