MLC Medical Form

MARITIME AND PORT AUTHORITY OF SINGAPORE
SHIPPING DIVISION
RECORD OF MEDICAL EXAMINATIONS OF SEAFARER
Part A to be completed by the Seafarer who is responsible for answering each question accurately.
Name in Full Sex:
(BLOCK CAPITALS) Male/Female
Date of Birth: day/month/year Place of Birth: Nationality:
Type of ID documents: NRIC No. / Dept: Deck / Engine / Catering / others Type of ship:
Passport No.: Rank:
Home Address: Routine and emergency duties: Trading area: e.g coastal
/ world wide
Declarations (please tick)

Have you ever had any of the following conditions?
Yes No Yes No
1. Eye/vision problem 18. Sleep problem
2. High blood pressure 19. Do you smoke, use alcohol or drugs?
3. Heart/vascular disease 20. Operation/surgery
4. Heart Surgery 21. Epilesy/seizures
5. Varicose veins/piles 22. Dizziness/fainting
6. Asthma/bronchitis 23. Loss of consciousness
7. Blood disorder 24. Psychiatric problems
8. Diabetes 25. Depression
9. Thyroid problem 26. Attempted suicide
10. Digestive disorder 27. Loss of memory
11. Kidney problem 28. Balance problem
12. Skin Problem 29. Severe headaches
13. Allergies 30. Ear(hearing, tinnitus/nose/throat problem
14. Infectious / contagious diseases 31. Restricted mobility
15. Hernia 32. Back or joint problem
16. Genital disorder 33. Amputation
17. Pregnancy 34. Fracture/dislocations
ide details:
Additional questions Yes No

35. Have you ever been signed off as sick or repatriated from a ship?
36. Have you ever been hospitalized?
37. Have you ever been declared unfit for sea duty?
Page 1 of 4
RECORD OF MEDICAL EXAMINATIONS OF SEAFARERS April 2013
38. Has your medical certificate even been restricted or revoked?
39. Are you aware that you have any medical problems, diseases or illnesses?
40. Do you feel healthy and fit to perform the duties of your designated position/occupation?
41. Are you allergic to any medication?
42. Are you using any non-prescription or prescription medication?
list the medications taken, the purpose(s) and the dosage:
I hereby declare that the personal declaration above is a true statement to the best of my knowledge.
Date Signature of Seafarer Name and Signature of Witness
I hereby authorize the release of all my previous medical records (including my last Seafarer Medical
Certificate) from any health professional, health institutions and public authorities to Dr.
________________________.
Date Signature of Seafarer Name and Signature of Witness
Part B Result of medical examinations

Eyesight
Use of glasses or contact lenses
No
Yes Type Purpose
Visual Acuity
Unaided Aided
Right eye Left eye Binocular Right eye Left eye Binocular
Distant Distant
Near Near
Visual fields
Normal Defective
Right eye
Left eye
Page 2 of 4
Colour Vision (please tick)
Not tested Normal Doubtful Defective
Hearing
Pure tone and audiometry (threshold values in dB)
500 Hz 1,000 Hz 2,000 Hz 3,000 Hz
Right ear
Left ear
Speech and whisper test (metres)

Normal Whisper
Right ear
Left ear
Clinical Findings
Height (cm) Weight (kg)

Pulse rate (per minute) Rhythm
Blood Pressure Systolic (mm Hg) Diastolic (mm Hg)
Urinalysis: Glucose : Protein: Blood:
Normal Abnormal
Head
Sinus, nose, throat
Mouth/teeth
Ears (general)
Tympanic membrane
Eyes
Ophthalmoscopy
Pupils
Eye movement
Lungs and chest
Breast examination
Heart
Skin
Varicose Vein
Vascular (inc. pedal pulse)
Abdomen and viscera
Hernia
Anus (not rectal exam)
G-U system
Upper and lower extremities
Spine (C/s, T/S, L/S)
Neurologic (full/brief)
Psychiatric
General appearance
Page 3 of 4
Chest X-ray
Not performed Performed on (day/month/year):
Results:
Other diagnostic test(s) and result(s):
Test Results: .
Medical ssment of fitness, with reasons for any limitations.
Assessment of fitness for service at sea (please tick)
results recorded above, I declare the seafarer medically:
Fit for look out duty Unfit for lookout duty
Visual aid required Visual aid not required
Deck Engine Catering Other

Service Service Service Service
Fit
Unfit
Without restrictions With restrictions
Description of restrictions (e.g. specific position, type of ship, trading area etc.)
Date Signature of Medical Pr

Medical Practitioner
*************
Page 4 of 4
MARITIME AND PORT AUTHORITY OF SINGAPORE
SEAFARER MEDICAL CERTIFICATE

This certificate is issued by the undersigned recognized medical practitioner to the named seafarer on behalf of the
Maritime and Port Authority of Singapore and meets both the requirements of the 2010 Manila amendments to the
International Convention on Standards of Trainings, Certification and Watchkeeping for Seafarers, 1978 (STCW
Convention) and the Maritime Labour Convention, 2006.
Name in Full Sex:

Male/Female
Date of Birth: day/month/year Nationality: Passport/NRIC No.:
Declaration of the recognized medical practitioner

Yes No
1 Identification documents were checked at the point of examination?
2 Hearing meets the standards in STCW Code Section A-I/9?
3 Unaided hearing satisfactory?
4 Visual acuity meets the standards in STCW Code Section A-I/9?
5 Colour vision meets the standards in STCW Code Section A-I/9?
Date of last colour vision test:
6 Fit for look out duty?
Is the seafarer free from any medical condition likely to be aggravated by service at sea or
7
to render the seafarer unfit for such service or endanger the life of person onboard?
8 No limitations or restrictions on fitness?
no
9 Date of examination: (day/month/year)

10 Expiry of certificate: (day/month/year)
** Maximum two years from date of examination unless the seafarer is under the age of 18
Date Signature of Official stamp

Medical Practitioner (name, licence number, address etc)
I have been informed of the content of the certificate and of the right to a review.
Signature of Seafarer
Page 1 of 1
SEAFARER MEDICAL CERTIFICATE - April 2013

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MARITIME AND PORT AUTHORITY OF SINGAPORE

Declarations (please tick)

Additional questions Yes No

list the medications taken, the purpose(s) and the dosage:

Date Signature of Seafarer Name and Signature of Witness

Date Signature of Seafarer Name and Signature of Witness

Part B Result of medical examinations

Yes Type Purpose

Not tested Normal Doubtful Defective

Speech and whisper test (metres)

Height (cm) Weight (kg)

Not performed Performed on (day/month/year):

Other diagnostic test(s) and result(s):

Medical ssment of fitness, with reasons for any limitations.

Assessment of fitness for service at sea (please tick)

results recorded above, I declare the seafarer medically:

Fit for look out duty Unfit for lookout duty

Visual aid required Visual aid not required

Deck Engine Catering Other

Without restrictions With restrictions

Date Signature of Medical Pr

SEAFARER MEDICAL CERTIFICATE

Name in Full Sex:

Declaration of the recognized medical practitioner

9 Date of examination: (day/month/year)

Date Signature of Official stamp

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