/ : .

MEDICAL CERTIFICATE FOR PERSONNEL SERVICE ON BOARD

With the requirementof the STCW Convention, 1978 as amended ond the Maritime Labour Convention 2006

SURNAME: -r A �AP£ 1-t,£ GIVEN NAME (Sr. ""1 A 12 C +I A 1; l

DATE OF BIRTH: PLACE OF BIRTH
ISMALEd
EX
DAY :)b MONTH LO YEAR ,0ei; CllY�U!'f'AfM,.I COUNTRY liJOOfl\;�IA FEMALEO
POSITION ON BOARD: MAILING ADDRESS OF APPLICANT:
MASTER 0 �c.. Af1Ul2-AtJ {,
DECK OFFICER 0 l,.lA�AtJ �A\'.l.�T
ENGINEERING OFACER 0 �AB, Ml HAl-lAS� %l,ATAf..l, %LAV-IG\l UTA�A
RADIO OPERATOR
RATING
DECLARATION OF THE AUTHORIZED PHYSICIAN
8
VISION COLOR TEST TYPE HEARING

C1
A
WITHOUT GLASSES WITH GLASSES BOOK
b../..b 0

I
RIGHT EYE -- LANTERN RIGHTEAR

-- --
®--
YELLOW RED
LEFT EYE U_b -- GREEN
-- BLUE
-- LEFT EAR
Contrmation that identitlc;atlon documents were checked at Iha point of examlnatlon: YES 0 NO O

I
Healing meets 1he slandards In STCW Code, Section A-119? YES 0 NO D NOT APUCABLE D
Unaided !loofio!I sausractor/1 YES 121 NO 0
'Cif

I
Visual acuity meets sl3ndards In STCW Code, Section A-119? YES NO O
Coloor vision meets standards In STCW Code, Section A-1/9? YES ,.J2{ NOD
(the vlsual 1esl It IS required every six years)
Dale of the last colour vision test: (Day/Monlh/Year) �0
l O', l :U,I�
,,
Are otasses or contact lenses necessary lo meet the re<iuired vision standards? YES DI' NO n �
Able for walchkeeping? YES E1 NO O

II
f9
a
Is applicant taking any non-preSC/lpUon or prescription medicaUons? YES O NO
Is th& seafarer free from any medical condiUon 1111ety aggravated by service al sea or to render the seafarers unfit for such service or lo
endanger the heal1h or other persons on board? YES NO O
Hereby I declare 111311 am in knOwtedge of Ille contents of the Physical Examination.

3!£�Signature of Applicant
TAl!APE f.11f MA!leHAEL..
Name of Applicant
.1� �A'/ ,-015
Dal&
i

<Bi)/
SHE) IS FOUND TO �I NOT FIT) FOR DUTY AS A (MASTER f DECK OFFCIER I
f
CIRCLE APPROPIATE CHOICE:
ENGINEERING OFFICER I RADIO OPERATOR I RATING) (WITH YI WITH THE FOLLOWING) RESmlCTIONS: i
.
NAME AND DEGREE or PHYstclAN:
ADDRESS: �lJO 'SliOt--lEi,
Ar. HA 121 A
:lL, SH
f·D. MOJ...I
�M-IJN o��t1KJJ14mra� -1-1w1eio iCf\l bf\H
-
NAME OF PHYSICIAN'S CERTIFICATING AUTHORITY: //,._((,·/ ��.\\.
1!.iY ·y;\\

»e
DATE OF ISSUE PHYSICIAN'S CERTIF.!CATE:

:� J mr�G tr) jl
l!

��. ��,
StGNATURE OF PHYSICIAN: 'STAMP r DATE: i� Ml\-� ?-0{$
� Y,lllCIAN:

EXPIRY DA TE OF CERTIFICATE: ?,� H�',I »-oi1 ';' ' / II

��··�
..-" ,
 Other diagnostic tests and results:

Test: Result:

Assessment of fitness for service at sea

On the basis of the examinee's personal declaration, my clinical examination and the diagnostic
test results recorded above, I declare the examinee medically:

I tzl Fit for look-out ID Not fit for look-out duty

Deck service Engine service Catering service Other services

Fit I I I I D r1
Unfit D r I D D
Without restrictions With restrictions Visual aid re uired Si

Describe restrictions (e.g .. specific positions, type of ship, trade area)

Medical certificate's date of expiration (day/month/year): 1-9 I D� I �9-1.

Date of medical certificate issued (day/month/year): 98 I Ob I !).()!�

Number of medical certificate:

Name of medical practitioner (typed or printed): Jlr· tf f\fi-1 A f · t), f-'ti,µ f+f,�

License number of medical practitioner: __

=»:
Address of medical practitioner: 12�1.JD � 111) 1-l b -:)L,. si1 SAP ul-( �A;:)MJ b \1 Ai.J H1!,0 - l-(Gt'100
..
Authorized by: Panama Maritime

Signature of medical practitioner: --�(C!?_

"'----------
'"-'
Seal:

F-ALM-011
Rev. 03
Page 4 de 4
Date: 13/03/2013.
 .·.

MEDICAL EXAMINATION

Sight

Use of glasses or contact lenses: Yes@(if yes, specify which type and for what purpose)

Visual acuity Visual fields

Una ides Aided Normal Defective
Right
eye
Left
eye
Binocular Right
eye
left
eye
Binocular Right eye
J
I Distant
b/{, b/r; left
eve J
I Color vision j 0Not tested I IQ.1Normal ! Oooubtful ! Ooefective
Hearing
Pure tone and audio metry (threshold values in dB) Speech and whisper test (metres)

Normal Whisper
SOOHz 1,000 Hz 2,000 Hz 3,000Hz
I Right ear Right ear
I Left ear Left ear

Clinical data

Height: ({/).. (cm) Weight: __Q£_ (kg)

Pulse rate: � (/minute) Rhythm: ).S

Blood pressure: Systolic : .!l:i._( mmHg) Diastolic : � ( mmHg)

Urinalysis: Glucose: _fl_ Protein: �Blood:�

Normal Abnormal Normal Abnormal

Head 1\/ Skin v D
Sinuses, nose, throat v Varicose venis ,J I I
Mouth/teeth v D Vascular (inc. Pedal pulses) v I I
Ears (general) Iv Abdomen and viscera 'I/ D
Tympanic membrane IV Hernias v I I
v J I I
. Eyes
Ophthalmoscopy rv D
Anus (not rectal exam.)
G-U system ,/ D
Pupils � Upper and lower extremities j I l
Eye movement v Spine (C/S, T/S and L/S) \I I I
Lungs and chest ,J Neurologic (full brief) v D
Breast examination v Psychiatric v I I
Heart v General appearance v I I
Chest X-ray 11 Not performed I VI Performed (day /month /year)
"'" l e« [ 90�
Results:

F-ALM-011
Rev. 03
Page 3 de4
Date: 13/03/2013.
 FORMAT FOR RECORDING MEDICAL EXAMINATIOS

OF SEAFARERS
Name (last, first, middle):

Date of birth (day/month/year): 2-6 I lb I 108&" Sex: g Male O Female

Passport No./discharge book No: ����������������������

Department: (deck/engine/radio/food handling/other):���������������

Routine and emergency duties:

�����������������������
Type of ship (container, tanker, passenger, fishing): ����������������-
Trade area (e.g., coastal, tropical, worldwide):

EXAMINEE'S PERSONAL DECLARATION (ASSISTANCE SHOULD BE OFFERED BY MEDICAL STAFF)

Have you ever had any of the following conditions?

Condition YES NO Condition YES NO

1. Eye I vision problem D liZI 19. Do you smoke,use alcohol or D 0
drugs?

2. High blood pressure D 0 20. Operation/surgery D t::I

3. Heart/vascular disease Iv' 21. Epilepsy/ seizures v
4. Heart surgery I\/ 22. Dizziness/fainting J
5. ·varicose veins/piles D v 23. Loss of consciousness D J
6. Asthma/bronchitis I v' 24. Psychiatric problems ..I
7. Blood disorder v 25. Loss of consciousness ...7
8. Diabetes D � 26. Attempted suicide D I

9. Thyroid problems Ii/ 27. Loss of memory

10. Digestive disorder v 28. Balance problems J
11. Kidney problems v 29. Severe headaches \}

12. Skin problems - � 30. Ear (hearing/ tinnitus) nose/throat ...... �

. 13. Allergies J 31.
problems
Restricted mobility v
14. lnfectious/contagius diseases v 32. Back or joint problems .r
15. Hernia \J 33. Amputation D �
16. Genital disorders \J 34. Fractures/dislocation ......
17. Pregnancy v

18. Sleep problem II

If any of the above questions were answered 11yes111 please give details

F-ALM-011
Rev. 03
Page 1 de 4
Date: 13/03/2013.
 Additional questions YES NO

35. Have you ever been signed off as sick or repatriated from a ship? �
36. Have you ever been hospitalized? IV
37. Have you ever been declared unfit for sea duty? I/
38. Has your medical certificate ever been restricted or revoked? IV
39. Are you aware that you have any medical problems, diseases or illness? v
40. Do you feel healthy and fit to perform the duties of your designed position/occupation? � -
41. Are you allergic to any medications? t-1

Comments:

42. Are you taking any non-prescription or prescription medications?

If yes, please list the medications taken and the purpose(s) and dosage(s).

I hereby certify that the person I declaration above is a true statement to the best of my knowledge.

Signature of examinee: --�-----------------------

Date (day/month/yei
r : a P
I 05/ �(�
Witnessed by:
---=!�"-------------------------�
Name: (typed or printed): E,ll,l, A . Sl.Jttl /11:-1 foU OJ • �- ¥- �f
I hereby authorize the release of all my previous medical records from any health professionals,
health, institutions and public authorities to Dr. MAit II- p. D. t'lC>f.tlAGA (the approved
medical practitioner).

�r!1
Signature of examinee: ---t-�
--�---------------------
-
Date (day/month/year):
�8 ,Oij
(Signature):--�
Witnessed by: ..........�'-"---------------------
-"+-

Date and contact details for previous medical examination (if known):
-----------

F-ALM-011
Rev.03
Page 2 de 4
Date: 13/03/2013.