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Canada – Nova Scotia Offshore Area Diving Operations Safety Transitional Regulations (SOR/2015-6)

Regulations are current to 2024-03-06

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: blank line First name(s): blank line Birth date blank lineSex: M/F

Ht: blank line cm   Wt: blank line 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 airwayEAMEardrumsEustacian tubeAudiometry
Rt. normal?Yes/NoYes/NoYes/NoYes/NoYes/No
Lt. normal?Yes/NoYes/NoYes/NoYes/NoYes/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   Skinfold thickness:  Lt. biceps: blank line mm   Lt. triceps: blank line mm   Lt. subscapular: blank line mm   Lt. sacroiliac: blank line 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%:blank line%

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 +

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 *

ShouldersHipKnees
Rt. normal?Yes/NoYes/NoYes/NoSpine normal? Yes/No
Lt. normal?Yes/NoYes/NoYes/NoLimbs & 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

ReflexesBJTJSJKJAJAbdo.PlantarClonus
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: blank line g/dL blank line HCT: blank line   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 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/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 by the Diver in Ink.

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.:

  • (b) Have you had a commercial diver’s medical examination before? Yes/No   If yes, when? blank line Where? blank line When did you first work under pressure?

  • (c) Date and place of your last bone and joint X-ray examination: blank line Other X-ray examinations: blank line 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 Asthmablank lineYes/No

    • 2 Hay fever or allergiesblank lineYes/No

    • 3 Allergy to drugs/medicationsblank lineYes/No

    • 4 Pneumothorax (collapsed lung)blank lineYes/No

    • 5 Pneumonia or pleurisyblank lineYes/No

    • 6 Bronchitis or other lung diseasesblank lineYes/No

    • 7 Tuberculosisblank lineYes/No

    • 8 Sinus troubleblank lineYes/No

    • 9 Ear diseaseblank lineYes/No

    • 10 Rheumatic feverblank lineYes/No

    • 11 Heart disease or murmurblank lineYes/No

    • 12 Chest pain or palpitationsblank lineYes/No

    • 13 Varicose veinsblank lineYes/No

    • 14 Bleeding tendencyblank lineYes/No

    • 15 Skin diseasesblank lineYes/No

    • 16 Diabetesblank lineYes/No

    • 17 Tropical diseasesblank lineYes/No

    • 18 Fits, blackouts or epilepsyblank 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 Sexually transmitted disease or sexually transmitted infectionblank lineYes/No

    • 29 Toothache, dental problemsblank lineYes/No

    • 30 Bone/joint disease or injuryblank lineYes/No

    • 31 Back injury or chronic back painblank lineYes/No

    • 32 Other serious illness or injuryblank lineYes/No

    • 33 Females: gynaecological disease or pregnancyblank lineYes/No

    • 34 Motion sicknessblank 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/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? blank line/day If you drink alcohol, how many glasses of wine blank line/week, of beer blank line/week and of spirits blank line/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:

Diver’s logbook inspected? Yes/No   Signed: blank line M.D.

If “no”, state reason: blank line Date: blank line

 

Date modified: