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SCHEDULE 5(Subparagraphs 26(b)(ii) and 62(b)(ii))

Supervisor’s or Ads Pilot’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 :blank line First name(s): blank line Birth date: blank line Sex: M/F

Ht: blank line cm Wt: blank line kg   Identifying features:

General appearance:

HEENT:  Normal?  Yes/No   Normal colour vision? Yes/No

Audiometry:   Rt. Normal? Yes/No   Lt. Normal? Yes/No

VISION:DistantDistant with glassesNearNear with glassesNormal visual fields?Normal Fundi?
Right:YES/NOYES/NO
Left:YES/NOYES/NO
Both:YES/NOYES/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 (e.g., 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 & 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:BJTJSJKJAJAbdo.PlantarClonus
Right:
Left:

Cerebellar function normal? Yes/No   Vestibular function normal? Yes/No   Rombergism present? Yes/No   Nystagmus present? Yes/No

LAB. INVESTIGATIONS:   Hb: blank lineg/dL blank lineHCT: blank lineFootnote *Sickle cell trait absent? Yes/NoFootnote * (initial medical examination)

Blood group: blank line BUN: blank lineFootnote *Creatinine: blank lineFootnote *Other

Urine PH: blank line Urine presence 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/NoDate for next examination:
Is the candidate fit to dive with restrictions?Yes/NoSpecify:
Name and address of examining doctor:
Signed: blank line Date: blank line Place: blank line

Part 2 — To Be Completed in Ink by the Supervisor or Ads Pilot, as the Case May Be.

Circle the correct answer as required. If in doubt, ask the advice of the examining doctor

  • (a) 
    Family name: blank line First name(s): blank line Birth date: blank line S.I.N.: blank line Provincial Health No.: blank line
  • (b) 
    Have you had an ADS pilot’s medical examination before? Yes/Noblank lineIf yes, when? blank line 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 Asthmablank lineYes/No

    • 2 Hay fever or allergiesblank lineYes/No

    • 3 Allergy to drugs/medicationsblank lineYes/No

    • 4 Pneumonia or pleurisyblank lineYes/No

    • 5 Bronchitis or other lung diseasesblank lineYes/No

    • 6 Tuberculosisblank lineYes/No

    • 7 Sinus troubleblank lineYes/No

    • 8 Ear diseaseblank lineYes/No

    • 9 High blood pressureblank lineYes/No

    • 10 Rheumatic feverblank lineYes/No

    • 11 Heart disease or murmurblank lineYes/No

    • 12 Chest pain or palpitationsblank lineYes/No

    • 13 Bleeding tendencyblank lineYes/No

    • 14 Skin diseasesblank lineYes/No

    • 15 Diabetesblank lineYes/No

    • 16 Tropical diseasesblank lineYes/No

    • 17 Fits, blackouts or epilepsyblank lineYes/No

    • 18 Dizziness, loss of balanceblank lineYes/No

    • 19 Head injury or concussionblank lineYes/No

    • 20 Stroke or paralysisblank lineYes/No

    • 21 Severe headache or migraineblank lineYes/No

    • 22 Nervous breakdown or mental illnessesblank lineYes/No

    • 23 Eye disordersblank lineYes/No

    • 24 Stomach/duodenal/peptic ulcerblank lineYes/No

    • 25 Gall bladder disorderblank lineYes/No

    • 26 Diarrhea or bowel diseaseblank lineYes/No

    • 27 Jaundice or hepatitisblank lineYes/No

    • 28 Kidney or bladder diseaseblank lineYes/No

    • 29 Bone/joint disease or injuryblank lineYes/No

    • 30 Back injury or chronic back painblank lineYes/No

    • 31 Other serious illness or injuryblank lineYes/No

    • 32 Motion sicknessblank lineYes/No

    • 33 Varicose veinsblank lineYes/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/Noblank lineIf yes, for what?
  • (h) 
    Are you taking, or have you ever taken, any medicines or drugs? Yes/Noblank lineIf 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), blank line, of (address) blank line, 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: blank line Date: blank line  Place: blank line

Part 3 — Physician’s Statement

Doctor’s remarks:

Candidate’s logbook inspected? Yes/No

If “no”, state reason:

Signed: blank lineM.D.

Date:

Date modified: