Canada – Nova Scotia Offshore Area Diving Operations Safety Transitional Regulations (SOR/2015-6)
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Regulations are current to 2024-06-11
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 : First name(s):
Birth date:
Sex: M/F
Ht: cm Wt:
kg Identifying features:
General appearance:
HEENT: Normal? Yes/No Normal colour vision? Yes/No
Audiometry: Rt. Normal? Yes/No Lt. Normal? 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 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 *
Return to footnote *At the discretion of the examining doctor
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: | 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
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 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/No | Date for next examination: |
Is the candidate fit to dive with restrictions? | Yes/No | Specify: |
Name and address of examining doctor: | ||
Signed: ![]() ![]() ![]() |
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:
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 health.
Signed: Date:
Place:
Part 3 — Physician’s Statement
Doctor’s remarks:
Candidate’s logbook inspected? Yes/No
If “no”, state reason:
Signed: M.D.
Date:
- Date modified: