Canada – Newfoundland and Labrador Offshore Area Diving Operations Safety Transitional Regulations (SOR/2015-5)
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Regulations are current to 2024-06-19
SCHEDULE 7(Subparagraph 52(b)(iii))
Diver’s Medical Examination Record
Part 1 — 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:
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
Nasal airway | EAM | Eardrums | Eustacian tube | Audiometry | |
---|---|---|---|---|---|
Rt. normal? | Yes/No | Yes/No | Yes/No | Yes/No | Yes/No |
Lt. normal? | Yes/No | Yes/No | Yes/No | Yes/No | Yes/No |
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 Skinfold thickness: Lt. biceps: mm Lt. triceps: mm Lt. subscapular: 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 (e.g., 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: Joint X-rays:Footnote *
Return to footnote *At the discretion of the examining doctor
Shoulders | Hip | Knees | |||
---|---|---|---|---|---|
Rt. normal? | Yes/No | Yes/No | Yes/No | Spine normal? Yes/No | |
Lt. normal? | Yes/No | Yes/No | Yes/No | Limbs & joints normal? Yes/No | |
CENTRAL NERVOUS SYSTEM: Power & tone of limbs normal? Yes/No Normal sensation to pinprick? Yes/No
Cranial nerves normal?
1 Yes/No
2 Yes/No
3 Yes/No
4 Yes/No
5 Yes/No
6 Yes/No
7 Yes/No
8 Yes/No
9 Yes/No
10 Yes/No
11 Yes/No
12 Yes/No
Reflexes | BJ | TJ | SJ | KJ | AJ | Abdo. | Plantar | Clonus |
---|---|---|---|---|---|---|---|---|
Right | ||||||||
Left |
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 2 — To Be Completed by the Diver in Ink.
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. Vestibulary 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 AsthmaYes/No
2 Hay fever or allergiesYes/No
3 Allergy to drugs/medicationsYes/No
4 Pneumothorax (collapsed lung)Yes/No
5 Pneumonia or pleurisyYes/No
6 Bronchitis or other lung diseasesYes/No
7 TuberculosisYes/No
8 Sinus troubleYes/No
9 Ear diseaseYes/No
10 Rheumatic feverYes/No
11 Heart disease or murmurYes/No
12 Chest pain or palpitationsYes/No
13 Varicose veinsYes/No
14 Bleeding tendencyYes/No
15 Skin diseasesYes/No
16 DiabetesYes/No
17 Tropical diseasesYes/No
18 Fits, blackouts or epilepsyYes/No
19 Head injury or concussionYes/No
20 Stroke or paralysisYes/No
21 Severe headache or migraineYes/No
22 Nervous breakdown or mental illnessesYes/No
23 Eye disordersYes/No
24 Stomach/duodenal/peptic ulcerYes/No
25 Gall bladder disorderYes/No
26 Diarrhea or bowel diseaseYes/No
27 Jaundice or hepatitisYes/No
28 Sexually transmitted disease or sexually transmitted infectionYes/No
29 Toothache, dental problemsYes/No
30 Bone/joint disease or injuryYes/No
31 Back injury or chronic back painYes/No
32 Other serious illness or injuryYes/No
33 Females: gynaecological disease or pregnancyYes/No
34 Motion sicknessYes/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 health.
Signed: Date: Place:
Part 3 — Physician’s Statement
Doctor’s remarks:
Diver’s logbook inspected? Yes/No Signed: M.D.
If “no”, state reason: Date:
- Date modified: