CONTRACTOR MEDICAL FORMS
Medical Questionnaire / Examination Form
PERSONAL DETAILS
Surname: Forenames:
Address: Tel No:
Other Address: Tel No:
Date of Birth: Mania] Status: M /S / D / W
GP's Name: Offshore Occupation/Job Title:
GP's Address:
Date of Last Offshore Medical: Date of Last Survival Course:
Fire Team Member: Yes/No
SOCIAL/OCCUPATIONAL HISTORY • , Yes No Write io
a nswers
Do you smoke? If so how many per day?
2. If an ex-smoker, when did you give up?
3. Average weekly alcohol consumption: state quantity and type
4. Have you been exposed to any known occupational hazard such as.
noise, radiation, dusts, asbestos, chemicals or lead?
5. Have you used protective clothing, safety glasses or hearing
protection? •
6. Have you ever developed any medical condition in connection with
your occupation? If so please give details e.g hearing loss / skin
condition /wheeze /backache /muscle strain/blood disease?
7. Have you suffered any industrial injury? If so please give details:
8. Have you had any previous audiometric screening? Was this normal?
State when and where.
9. Have you had previous lung function screening? Was this normal?
State when and where.
10. Have you ever been rejected from employment on medical grounds?
I I. Have you received compensation, or is there any industrial claim
pending?
12. Have you ever been medivaced from an offshore installation?
EXAMINING PHYSICIAN'S COMMENTS
UKOAA - Medical Questionnaire. doc Page: 1 of 6
General Medical Questionnaire
MEDICAL HISTORY REQUIRING SPECIAL CONSIDERATION
DO YOU HAVE OR HAVE YOU BEEN DIAGNOSED AS SUFFERING FROM ANY OF THE
FOLLOWING? Please circle'and elaborate
I. Chest pain / heart disease YES NO
2. High blood pressure / stroke YES NO
3. Asthma / Epilepsy / Diabetes YES NO
4. Peptic ulcer disease YES NO .
5. Kidney disease (e.g. stones) YES NO
6. Psychiatric disorder (e.g. anxiety, YES NO
depression)
7. Tuberculosis YES NO
8. Cancer YES NO
DO ANY OF YOUR IMMEDIATE FAMILY (PARENTS/BROTHERS/SISTERS) HAVE A HISTORY OF
ANY OF THE ABOVE CONDMONS? PLEASE SPECIFY:
EXAMINING PHYSICIAN'S COMMENTS
DO YOU HAVE OR HAVE YOU HAD ANY SIGNIFICANT OR RECURRENT PROBLEMS WITH THE .
Please circle and elaborate
I. Backache /joint or muscular pain YES NO
2. Hernia / rupture YES NO
3. Visual impairment YES NO
4. Perforated eardrum / discharge from ear YES NO
5, Recurrent indigestion YES NO
6. Jaundice / hepatitis / gall bladder disease YES NO
7. Change in bowel habit/diarrhoea YES NO
8. Blood in stool / piles, haemorrhoids YES NO
9. Shortness of breath / coughing up blood YES NO
10. Recurrent bronchitis / pneumonia YES NO
II. Blood in urine / kidney complications / YES NO
stones
12. Headaches / migraine / dirziness YES NO
EXAMINING PHYSICIAN'S COMMENTS
UKOAA - Medical Questionnaire.doc Page: 2 of 6
General Medical Questionnaire
13. Varicose veins YES NO
14. Skin trouble (e.g dermatitis / eczema) YES NO
15. Surgical operations YES NO
16. Hospitalisation YES NO
17. Fear of flying/ fear of heights YES NO
I8. Tropical diseases / venereal disease / HIV YES NO
19. History of alcohol / drug abuse YES NO
20. Do you have any allergies? Please list YES NO '
21. Do have any current illnesses? Please list. ..Y ES NO
22. Are you receiving any medication, YES NO
including vitamins, etc, at present?
Please list_
23. Have you attended a dentist in the last YES NO
year?
24. Are you undergoing dental treatment? YES NO
25. Travellers Vaccinations: Date of Last Booster: Travellers Vaccinations: Date of Last Booster.
Tetanus Diphtheria
Polio Hep A
Typhoid Hep B
Yellow Fever Others
FOR FEMALES ONLY- HAVE YOU EVER HAD?
Please circle and elaborate
26. An abnormal smear / breast disease YES NO
27. Gynaecological problems e.g. pelvic infection YES NO
28. Complications of Pregnancy YES NO
29. Please give date of last menstrual period
EXAMINING PHYSICIAN'S COMMENTS
"I DECLARE THE ABOVE TO BE TRUE TO THE BEST OF MY KNOWLEDGE. I AGREE THAT THE
RESULT OF MY MEDICAL EXAMINATION, INCLUDING APPROPRIATE INVESTIGATIONS CARRIED
OUT IN ORDER TO ESTABLISH MY MEDICAL FITNESS MAY BE REVEALED TO A COMPANY
MEDICAL OFFICER IF REQUIRED. I ACCEPT THE TRANSFER OF MY MEDICAL FILES TO OTHER
DOCTORS WORKING FOR THE COMPANY IN WHICH I MAY GAIN EMPLOYMENT."
NON DECLARATION OF SIGNIFICANT MEDICAL PROBLEMS MAY RESULT IN TERMINATION
OF EMPLOYMENT.
SIGNATURE OF EXAMINEE . DATE:
I iwnd MpriiI7a1 n,ioctinnnnina Arn Pan■a• 7 nf
Medical Examination
To Be Completed By Examining Physician
PROOF OF IDENTITY PRODUCED YES/NO
Predict Urinalysis
Age Height Weight BM I BP Pulse, Peak ed
Flow PFR
Protein Blood Glucose
Ph Temp
Vision - Distance Vision - Near Colour VDU
L Aided L BOTH L Aided L BOTH Normal Abnormal
R Aided R R Aided R
Normal Abnormal Elaborate On Abnormal Findin
I EYES/PUPILS
2 EAR, NOSE & THROAT
3 TEETH (Date of last dental check)
4 LUNGS/CHEST
5 CARDIOVASCULAR
6 ABDOMEN
7 HERNAL ORIFICES
8 RECTAL
9 GENITOURINARY
10 MUSCULOSKELTAL (Spine &
Back)
II SKIN
12 VARICOSE VEINS
13 NEUROLOGICAL
14 BREASTS
15 IDENTIFYING MARKS (Tattoos /
Scars)
PHYSICIAN TO COMMENT ON ANY ABNORMALITIES
UKOAA - Medical Questionnaire. doc Page: 4 of 6
INVESTIGATIONS Normal Abnormal Normal Abnormal
1 AUDIOMETRIC SCREENING 6 CHEST X-RAY (If
indicated)
2 SUBSTANCE ABUSE 7 DENTAL
SCREENING (Spec No.) CERTIFICATION
(If indicated)
3 URINALYSIS 8 ECG (If indicated)
4 PEAK FLOW 9 STOOL CULTURE
5 VITALOGRAPH (If indicated) 10 Blood work •
• Blood analysis including
Blood Chemistry'
CBC with Differential'
VORL (Syphilis Serology'
Gamma GT and drug screening •
Blood Type with Rh (If type unknown)
G-6-PD (P.L. Vivax areas only) (For assignments to certain countries)
Hepatitis A Antibody Total 2 (Endemic areas only) (if not already immune)
TB Mantoux/PPD Test (Unless previously positive)
Cholesterol Profile —
Stool for Ova & Parasites and Giardia Antigen'
Urinalysis with Microscopic'
GENERAL COMMENTS
CONCLUSION
I CERTIFY THAT
IS FIT / UNFIT FOR OFFSHORE EMPLOYMENT AND TO UNDERTAKE SURVIVAL TRAINING, IN KEEPING
WITH CURRENT UKOOA HEALTH ADVISORY COMMITTEE GUIDELINES ON MEDICAL FITNESS FOR
OFFSHORE WORK.
DATE OF MEDICAL DATE OF EXPIRY
SIGNED
Examining Physician
UKOAA - Medical Questionnaire. doc Page: 5 of 6
Occupational & JOSE G. ACEVEDO, MD, MPH
Environmental Internal Medicine
Occupational & Environmental Medicine
Medicine of MIRNA A. PUESAN, MD, MPH
[14 11 Houston Occupational & Environmental Medicine
Unrestricted Offshore Work Certificate
Medical Certificate of Fitness for Offshore Work
Issued in accordance with Oil and Gas UK guidelines
Certificate number:
Name: Date of Birth:
Company Name:
Occupation:
This individual has been examined in accordance with Oil & Gas UK Guidelines, and is
Medically Fit for Unrestricted Offshore Work.
Examining Physician Name: Jose Acevedo, MD, MPH
Oil & Gas UK PIN No. OGUK/2006/953
Date of Examination:
Date of Expiry of Certificate:
Signed.
z62.0 Tanglewilde Street • Houston, Texas 77063 • 713.785.1272 • Fax: 713.785.1295
UKOOA
Oil and Gas for Britain
UKOOA MEDICAL EXAMINATION
Employee Name: Physician Name: Jose G. Acevedo M.D.,M.P.H.
9701 Richmond Ave. # 115
Houston, TX 77042
Ph: 713-785-1272
Date of Examination:
Age: Age Group: < 20
(Circle) 20-29
30-39
40-49
50-59
60+
Outcomes: PASS
FAIL
RESTRICT
Reason for FAIL or RESTRICT;
THIS FORM IS FOR THE USE OF THE EXAMINING PHYSICIAN ONLY AND SbOULD NO BE SENT TO
UKOOA AS PART OF THE ANNUAL RETURN,
