PART I — To be completed by the physician. All abnormal findings shall be recorded on the diver’s 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: __________

__________

HEENT:

Normal? Yes/No

URTI: Normal?  Yes/No

Teeth & gums normal? Yes/No

Any dentures? Yes/No

Neck normal? Yes/No

Sinuses normal? Yes/No

Dental X-rays normal? Yes/No/Not doneFootnote ^*

Normal colour vision? Yes/No

SKIN:

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

Lymph glands normal? Yes/No

Skinfold thickness:

Lt. biceps: mm Lt. triceps: mm

Lt. subcaphular: mm

Lt. sacroiliac: mm 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 FVC: FEV₁/FVC%: %

CARDIOVASCULAR:

BP /  Pulse: /min.

Varicose veins? Yes/No

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

Stress ECG normal? Yes/No/Not doneFootnote ⁺

• Return to footnote ⁺Mandatory for divers over 35 years of age

ABDOMEN:

Organomegaly? Yes/No Masses present? Yes/No Herniae present? Yes/No

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

MUSCULO-SKELETAL:

• Return to footnote ^*At the discretion of the examining doctor

Spine normal? Yes/No

Limbs & joints normal? Yes/No

CENTRAL NERVOUS SYSTEM:

Power & tone of limbs normal? Yes/No

Normal sensation to pinprick? Yes/No

Cerebellar function normal? Yes/No

Vestibular function normal? Yes/No

Rombergism present? Yes/No   

Nystagmus present? Yes/No

EEG normal? Yes/No/Not DoneFootnote ^*

Electronystagmograms normal? Yes/No/Not DoneFootnote ^*

LAB. INVESTIGATIONS:

Hb: g/dL HCT:

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 diver in ballpoint pen. 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 a commercial diver’s medical examination before? Yes/No

If yes, when? Where? __________

When did you first work under pressure? __________

• (c) Date and place of your last bone and joint X-ray examination: __________

__________

Other X-ray examinations: __________

Give details of vaccinations: __________

• (d) Have you ever had any of the following medical problems?

  • 1. Skin bends? Yes/No

  • 2. Limb bends? Yes/No

  • 3. Spinal or cerebral bends? Yes/No

  • 4. Pulmonary decompression sickness? Yes/No

  • 5. Vestibular bends? Yes/No

  • 6. Pulmonary barotrauma (ruptured lung)? Yes/No

  • 7. Arterial gas embolism? Yes/No

  • 8. Problems with compression? Yes/No

  • 9. Dysbaric osteonecrosis (bone necrosis)? Yes/No

  Give details of any positive answers, including date and number of times the problem has occurred: __________

  __________

• (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.	Pneumothorax (collapsed lung)	Yes/No
  5.	Pneumonia or pleurisy	Yes/No
  6.	Bronchitis or other lung diseases	Yes/No
  7.	Tuberculosis	Yes/No
  8.	Sinus trouble	Yes/No
  9.	Ear disease	Yes/No
  10.	Rheumatic fever	Yes/No
  11.	Heart disease or murmur	Yes/No
  12.	Chest pain or palpitations	Yes/No
  13.	Varicose veins	Yes/No
  14.	Bleeding tendency	Yes/No
  15.	Skin diseases	Yes/No
  16.	Diabetes	Yes/No
  17.	Tropical diseases	Yes/No
  18.	Fits, blackouts or epilepsy	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.	Venereal disease	Yes/No
  29.	Toothache, dental problems	Yes/No
  30.	Bone/joint disease or injury	Yes/No
  31.	Back injury or chronic back pain	Yes/No
  32.	Other serious illness or injury	Yes/No
  33.	Females: gynaecological disease or pregnancy	Yes/No
  34.	Motion sickness	Yes/No

Give details of any positive (Yes) 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 used 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 welfare.

Signed: Date: Place: __________

PART III — Physician’s Statement

Doctor’s remarks: __________

Diver’s logbook inspected? Yes/No

If “no”, state reason: __________

Signed: M.D.

Dated: