FRM10 Rev.

01/23

Kenya Maritime Authority

MEDICAL EXAMINATION REPORT

PART A: TO BE COMPLETED BY APPLICANT

You should complete this section bef ore your medical

examination. Yes No

You must take a suitable means of identif ication (national Are you in good health now? ☐ ☐
ID, passport, driving license) with you to the examination Do you drink alcohol? ☐ ☐
If yes, how much and how often?
First Name: Last Name :

ID/Passport No.: Date of Birth :

Do you smoke tobacco? ☐ ☐
Gender: ☐ Male ☐ Female If no, have you smoked in the past? ☐ ☐
Home address :
Have you been absent from work due to sickness or ☐ ☐
injury for more than 14 consecutive days over past two
years?

If no, have you smoked in the past? ☐ ☐

Have you now, or have you previously had any of the
Yes No
following?
PRIVACY NOTICE Anxiety or depression ☐ ☐
Please read carefully for information and guidance
Migraine or persistent headaches ☐ ☐
Epilepsy or fits ☐ ☐
The inf ormation contained on this f orm and its associated
documents will be used f or the purposes of assessing your Poliomyelitis or other paralysis ☐ ☐
medical f itness f or duty at sea and f or KMA audit purposes. Attack of unconsciousness or weakness, ☐ ☐
This inf ormation may be exchanged between your dizziness or turns ☐ ☐
examining medical of f icer and your treating medical
practitioner and/or any medical panel convened to assess Have you ever been declared unfit for Yes No
your f itness f or duty at sea. If you do not meet the medical duty at seas? ☐ ☐
f itness standard f or duty at sea, you and your employer will If yes, state when, for how long and for what reason :
be advised of this on the Medical Certif icate.

Yes No
Are you taking any medications at present?
☐ ☐
Do you have or have you had an eye disorder
or injury?
☐ ☐ Yes No
NOTE: If you wear glasses, corneal or contact lenses, bring them with you to

the examination. CHROMAGEN LENSES MUST NOT BE WORN

Has your medical certificate ever been restricted or ☐ ☐
cancelled or have you ever declared unfit?
PERSONAL HISTORY If yes, give details :

Position onboard vessel:

☐Master ☐Engine room rating ☐ AB Engine

☐ Engineer Officer ☐Deck rating ☐ Catering

☐Deck Officer ☐AB Deck ☐ Other

Have you ever been signed off as sick or repatriated Yes No

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KMA – Seafarers Medical Examination Report
 FRM10 Rev. 01/23

Kenya Maritime Authority

MEDICAL EXAMINATION REPORT

from a ship due to: Diabetes ☐ ☐
Discharge from ears or perforated eardrum? ☐ ☐ Dermatitis/eczema/skin eruptions ☐ ☐
Ringing in the ears or disturbances of balance? ☐ ☐ Allergy conditions including hay fever ☐ ☐
Deafness? ☐ ☐ Any abnormality of the immune ☐ ☐
Nasal or sinus trouble? ☐ ☐ Any allergic reaction to any serum, drug or ☐ ☐
Persistent husky voice or frequent sore throat? ☐ ☐ medicine (including anaesthetic agents) and vaccines.
Goiter or Thyroid disease? ☐ ☐ Any disease such as malaria, typhoid, amoebiasis, giardia ☐ ☐
Have you now, or have you previously had Severe tooth or gum trouble ☐ ☐
Yes No
any of the following? Impacted wisdom teeth ☐ ☐
High blood pressure ☐ ☐ Any obstetric or gynaecological problems ☐ ☐
Disease of the heart, arteries or blood vessels ☐ ☐ Lumbago, sciatica or other back trouble ☐ ☐
Operation of the heart ☐ ☐ Any form of arthritis or stiff joints ☐ ☐
Anemia or any other disease of the blood ☐ ☐ Joint injuries ☐ ☐
Swelling of the ankles ☐ ☐ Injury of the neck or back ☐ ☐
Palpitations ☐ ☐ Repetitive Strain Injury, tennis elbow, tendonitis ☐ ☐
Varicose veins or abnormal bleeding ☐ ☐ Broken bones ☐ ☐
Rheumatic fever ☐ ☐ Gout ☐ ☐
Disease of the liver (including jaundice or hepatitis) ☐ ☐ Are you pregnant? ☐ ☐
Disease or ulcer of the stomach or duodenum ☐ ☐
Recurrent abdominal pain/persistent indigestion ☐ ☐ Please give details of any complaint, illness or injury not previously
Appendicitis ☐ ☐ mentioned:
Gallbladder disease ☐ ☐
Disease of the bowels ☐ ☐
Hemorrhoids (piles) ☐ ☐
Hernia (rupture) ☐ ☐
Recent change in weight ☐ ☐
Asthma ☐ ☐
Bronchitis or emphysema ☐ ☐
Tuberculosis ☐ ☐ Are you aware of ANY circumstances regarding your health Yes No
Persistent breathlessness ☐ ☐ which may interfere with the satisfactory discharge of the ☐ ☐
Persistent cough ☐ ☐ duties of your designated position / occupation?
Collapsed lung ☐ ☐ If yes, give details:
Other lung disease/abnormal x-ray ☐ ☐
Infection of bladder ☐ ☐
Kidney disease or kidney stone ☐ ☐
Difficulty in passing urine ☐ ☐
Any abnormality of the urine ☐ ☐
Sexually transmitted disease ☐ ☐
Any form of cancer or unexplained lumps ☐ ☐

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KMA – Seafarers Medical Examination Report
 FRM10 Rev. 01/23

Kenya Maritime Authority

MEDICAL EXAMINATION REPORT

The following should be signed in the presence of the examining medical officer:

Declaration
I hereby declare that, to the best of my knowledge my personal statements are true and correct :

Applicant’s signature: ………………………………………… Date: ………………………….

Authority to divulge medical information

If , as a result of the subsequent examinations f or the purposes of assessing my medical f itness f or duty at sea, the examining
medical of f icer requires relevant medical details f rom my treating medical advisor(s), permission is hereby granted to obtain
inf ormation f rom:

Dr.:…………………………………… Dr.:……………………………………

Address……………………………… Address………………………………

Phone: ………………………………. Phone: ……………………………….

Dr.:…………………………………… Dr.:……………………………………

Address……………………………… Address………………………………

Phone: ………………………………. Phone: ……………………………….

Applicant’s signature: ………………………………………… Date: ………………………….

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KMA – Seafarers Medical Examination Report
 FRM10 Rev. 01/23

Kenya Maritime Authority

MEDICAL EXAMINATION REPORT

PART B: TO BE COMPLETED BY THE MEDICAL EXAMINER

Medical Examiner’s name Color vision: (Ishihara test. Testing only required every six years)

☐ Not tested ☐ Normal ☐ Doubtful ☐ Defective

Date of last colour vision test:
Telephone no.:
HEARING
Applicant’s proof of identity Pure tone and audiometry (threshold values in dB)
☐Photo driver’s license No………………….. 500Hz 1000Hz 2000Hz 3000Hz
☐Passport No……………………..
Right ear
☐Other……………………………………………………
Left ear
Applicant’s Position on board vessel Speech and Whisper test (metres)

Normal Whisper

Right ear
Note: Requirements regarding hepatitis, colour vision etc
Left ear
will depend on the applicant’s position on board vessel,
please Ref er to the Guidelines.
CLINICAL FINDINGS
HEIGHT/WEIGHT Pulse rate ……………/minute

Height (without shoes) ……………………………..Metres Blood pressure Systolic……..(mmHg) Diastolic……..(mmHg)

Weight ………………………………… Kgs Urinalysis Glucose………... Protein…………. Blood……..……

2 Normal Abnormal
Body Mass Index(BMI) = Weight in kgs)/(Height in mtrs)
(……………………………………. Head ☐ ☐
Sinuses, nose, throat ☐ ☐
Mouth/teeth ☐ ☐
SIGHT Ears (general) ☐ ☐
Use of glasses or contact lenses: Yes No Tympanic membrane ☐ ☐
(if yes, specify which type and for what purpose): Eyes ☐ ☐
Ophthalmoscopy ☐ ☐
☐ ☐ Pupils ☐ ☐
Eye movement ☐ ☐
Visual acuity: Lungs and chest ☐ ☐
Breast examination ☐ ☐
Unaided Aided
Heart ☐ ☐
Right eye Left eye Binocular Right eye Left eye Binocular Skin ☐ ☐
Distant Varicose veins ☐ ☐
Vascular (inc. pedal pulses) ☐ ☐
Near
Abdomen and viscera ☐ ☐
Visual fields: Hernia ☐ ☐
Normal Defective Anus (not rectal exam) ☐ ☐
G-U system ☐ ☐
Right eye ☐ ☐
Upper and lower extremities ☐ ☐
Left eye ☐ ☐ Spine (C/S, T/S and L/S) ☐ ☐
Neurologic (full/brief) ☐ ☐
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KMA – Seafarers Medical Examination Report
 FRM10 Rev. 01/23

Kenya Maritime Authority

MEDICAL EXAMINATION REPORT

Psychiatric ☐ ☐
General appearance ☐ ☐

CHEST X-RAY Visual aid required : ☐ Yes ☐ No

☐ Not Performed
☐ Performed on (day/month/year): Medical certif icate’s date of expiry (day/month/year):_____
Results:

Date medical certif icate issued (day/month/year): ______

ECG REPORT Medical certif icate no:______________

Attach report and tracing to this form; Stress ECG required if clinically
indicated; Baseline tracing only to be attached to this document)
ECG Results: Signature of medical practitioner: ____________________

Medical practitioner inf ormation (name, license number,

address)________________________________________
Date:
_______________________________________________

RESPIRATORY _______________________________________________
Attach the spirometry report/tracing;
Results:

Date:

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: ~End~

☐ Fit for lookout duty

☐ Not Fit for lookout duty

Deck service Engine service Catering serviceOther services

Fit ☐ ☐ ☐ ☐
Unfit ☐ ☐ ☐ ☐
☐ Without Restrictions ☐ With Restrictions

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

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KMA – Seafarers Medical Examination Report