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

Regulations are current to 2020-10-05

SCHEDULE V(Paragraphs 27(b) and 64(b))

Supervisor’s or Pilot’s Medical Examination Record — Part I

All abnormal findings shall be recorded on the supervisor’s or pilot’s medical examination record.

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

Ht: blank linecmblank lineWt: blank line kgblank lineIdentifying features: blank line

General appearance: blank line

  • HEENT: Normal? Yes/No
  • Normal colour vision? Yes/No
  • Audiometry:
    • Rt. Normal? Yes/No
    • Lt. Normal? Yes/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
    • 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 Done:Footnote *
  • 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 (eg. 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 and joints normal? Yes/No
  • CNS:
    • 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
    ReflexesBJTJSJKJAJAbdo.Plantar Clonus
    Right
    Left
    • Cerebellar function normal? Yes/No
    • Vestibular function normal? Yes/No
    • Rombergism present? Yes/No
    • Nystagmus present? Yes/No

LAB. INVESTIGATIONS:

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 unfit permanently? Yes/No

  • Is the candidate unfit temporarily? Yes/No Date for next examination: blank line
  • Is the candidate fit with restrictions? Yes/No Specify: blank line

Name and address of examining doctor: blank line

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

Supervisor’s or Pilot’s Medical Examination Record — Part II

To be completed by the candidate 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 pilot’s medical examination before? Yes/Noblank lineIf yes, when? blank line Where? blank line
  • (c) 
    Date and place of any X-ray examinations: blank line
  • (d) 
    Give details of vaccinations: 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 Pneumonia or pleurisy

      • 5 Bronchitis or other lung diseases

      • 6 Tuberculosis

      • 7 Sinus trouble

      • 8 Ear disease

      • 9 High blood pressure

      • 10 Rheumatic fever

      • 11 Heart disease or murmur

      • 12 Chest pain or palpitations

      • 13 Bleeding tendency

      • 14 Skin diseases

      • 15 Diabetes

      • 16 Tropical diseases

      • 17 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
      • 18 Dizziness, loss of balance

      • 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 Kidney or bladder disease

      • 29 Bone/joint disease or injury

      • 30 Back injury or chronic back pain

      • 31 Other serious illness or injury

      • 32 Motion sickness

      • 33 Varicose veins

    • 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

    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
  • (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

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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 well-being.

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

Doctor’s Remarks: blank line

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

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

Date modified: