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Canada Oil and Gas Diving Regulations (SOR/88-600)

Regulations are current to 2020-09-09

SCHEDULE VII(Paragraph 53(b))

Diver’s Medical Examination Record — Part I

All abnormal findings shall be recorded on the diver’s medical examination record.

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

Ht: blank linecm Wt: blank linekgblank line Identifying features: blank line

General appearance: blank line

  • 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: DistantDist. with glassesNearNear with glassesNormal visual fields?Normal fundi?
Right

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Yes/No

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Yes/No

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Left

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Yes/No

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Yes/No

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Both

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Yes/No

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Yes/No

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  • 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 (eg. Ruffier test) normal? Yes/No
    • Stress ECG normal? Yes/No/Not done.Footnote +
  • 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 for *ShouldersHipKnees
    Rt. normal?Yes/NoYes/NoYes/No
    Lt. normal?Yes/NoYes/NoYes/No
    • Spine normal? Yes/No
    • Limbs & joints normal? Yes/No
  • CNS:
    • Power & tone of limbs normal? Yes/No
    • Normal sensation to pinprick? Yes/No
    • Cranial nerves normal?
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • 7
    • 8
    • 9
    • 10
    • 11
    • 12
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    ReflexesBJTJSJKJAJAbdo.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: blank line g/dLblank line
    • HCT: blank line
    • Sickle cell trait absent? Yes/NoFootnote * (initial medical examination)
    • Blood group: blank line
    • Creatinine: blank lineFootnote *
    • Other blank line
    • 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/No Date for next examination:blank line
  • Is the candidate fit to dive with restrictions? Yes/No Specify: blank line
  • Name and address of examining doctor: blank line
    • Signed: blank line Date: blank line Place: blank line

Diver’s Medical Examination Record — Part II

To be completed by the diver in ballpoint pen. Circle correct answer. 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 a commercial diver’s medical examination before? Yes/Noblank lineIf yes, when? blank line Where? blank line

    When did you first work under pressure? blank line

  • (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: blank line

  • (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 (yes) answers, including date and number of times the problem has occurred: blank line

    blank line

  • (e) 
    Do you have, or have you ever had or been treated for, any of the following medical conditions?
      • 1 Asthma

      • 2 Hay fever or allergies

      • 3 Allergy to drugs/medications

      • 4 Pneumothorax (collapsed lung)

      • 5 Pneumonia or pleurisy

      • 6 Bronchitis or other lung diseases

      • 7 Tuberculosis

      • 8 Sinus trouble

      • 9 Ear disease

      • 10 Rheumatic fever

      • 11 Heart disease or murmur

      • 12 Chest pain or palpitations

      • 13 Varicose veins

      • 14 Bleeding tendency

      • 15 Skin diseases

      • 16 Diabetes

      • 17 Tropical diseases

      • 18 Fits, blackouts or epilepsy

    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
      • 19 Head injury or concussion

      • 20 Stroke or paralysis

      • 21 Severe headache or migraine

      • 22 Nervous breakdown or mental illnesses

      • 23 Eye disorders

      • 24 Stomach/duodenal/peptic ulcer

      • 25 Gall bladder disorder

      • 26 Diarrhea or bowel disease

      • 27 Jaundice or hepatitis

      • 28 Venereal disease

      • 29 Toothache, dental problems

      • 30 Bone/joint disease or injury

      • 31 Back injury or chronic back pain

      • 32 Other serious illness or injury

      • 33 Females: gynaecological disease or pregnancy

      • 34 Motion sickness

    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No
    • Yes/No

    Give details of any positive (Yes) answers, including dates: blank line

    blank line

  • (f) 
    Give date and place of any hospital admissions or operations: blank line

    blank line

  • (g) 
    Have you been under medical treatment during the past year? Yes/Noblank lineIf yes, for what? blank line

    blank line

  • (h) 
    Are you taking, or have you ever taken any medicines or drugs? Yes/Noblank lineIf yes, specify: blank line

    blank line

  • (i) 
    How much do you smoke? blank line/day How much do you drink? blank line/week Have you ever suffered from any health problems related to mind-altering, “street” or addictive drugs? Yes/Noblank lineIf yes, give details: blank line

    blank line

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 welfare.

Signed: blank line Date: blank line Place: blank line

Doctor’s remarks: blank line

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Diver’s logbook inspected? Yes/Noblank lineSigned: blank line M.D.

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

 
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