Diver's Medical Examination Record

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

Surname _____________________ First Name ______________ Middle Initial______

Birth Date _________________ Sex _________

Identifying Features ______________________________________________________________

Height __________ Weight __________

Medical Status Normal? *At the discretion of the examining doctor. Mandatory for divers >35.

HEENT: yes/not URTI: yes/no Teeth and Gums: yes/no Dentures: yes/no Neck: yes/no

Skin: Rash: yes/no Infection: yes/no Parasites: yes/no Lymph Glands: yes/no Breasts: yes/no

Skinfold Thickness: l.t. biceps______mm l.t. triceps______mm l.t. subscapular______mm

sacroiliac ______ mm

Respiratory: Chest Scars or Deformity: yes/no Chest Ausculation: yes/no

Adventitious Sounds: yes/no

Current X-Rays: yes/no Fvc: FEV/FVC% Sinuses: yes/no Dental X-Rays: yes/no

Audiometry
Nasal Airway
Ear
Eardrums
Eustachian Tubes

Right Normal
yes/no
yes/no
yes/no
yes/no

Left Normal
yes/no
yes/no
yes/no
yes/no

Vision
Right
Left
Both

Distance with Glasses
____________
____________
____________

Near
____________
____________
____________

Near with Glasses
____________
____________
____________

Visual Fields
yes/no
yes/no
yes/no

FUNDI
yes/no
yes/no
yes/no

Cardiovascular: Varicose Veins: yes/no Peripheral Pulses/Circulation: yes/no

Apex Beat: yes/no Heart Sounds: yes/no Murmurs Present: yes/no ECG: yes/no

Stress ECG: yes/no Exercise Tolerance Test: yes/no

BP______/_______ PULSE______/min

Abdomen: Organomegly: yes/no Masses Present: yes/no Hernia Present: yes/no

Genitourinary System: yes/no

Rectal: yes/no

Muscular-skeletal
Shoulders
Hip
Knees

Right
yes/no
yes/no
yes/no

Left
yes/no
yes/no
yes/no

*Joint X-rays: yes/no

Spine: yes/no

Limbs and Joints: yes/no

CNS: Power & Tone of Limbs: yes/no Sensation of 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

Cerbral Functions: yes/no Vestibular Functions: yes/no Romberfish Present: yes/no

Nystagmus Present: yes/no EEG: yes/no/not done Electronystagmograms yes/no/not done

Reflexes
BJ
TJ
SJ
KJ
ABDL
Plantar Clonus

Right
_________
_________
_________
_________
_________
_________

Left
_________
_________
_________
_________
_________
_________

Lab Investigations: HB _______g/ HCT________ Sickle Trait Absent: yes/no

*(Initial Medical Exam)

Blood Group _______ BUN _______ *Creatinine _________

*Other__________________________________

Urine PH _____________ Urine Free or Albumin: yes/no Sugar: yes/no Protein: yes/no

Blood: yes/no

Comments on any abnormalities detected:

Is the candidate free from physical defects: yes/no

Has the candidate the physique for prolonged exertion: yes/no

Fit for work in all climates: yes/no

Information is up to date: yes/no

Permanently unfit to dive: yes/no

Temporarily unfit to dive: yes/no

Is the candidate fit to dive with restrictions: yes/no

Specify________________________________________________________________________

______________________________________________________________________________

 

Date of Examination: _______________

Name and Address of Examining Doctor:
______________________________

______________________________

______________________________

Signed_____________________ Date _____________ Place________________________________

Medical exam is in compliance with the code for medical examination of divers dated July 4, 1994 issued by the Ontario Ministry of Labour.