Canada Oil and Gas Diving Regulations (SOR/88-600)

Supervisor’s or Pilot’s Medical Examination Record — Part I

All abnormal findings shall be recorded on the supervisor’s or pilot’s medical examination record.

Family name: First name(s): Birth date: Sex: M/F

Ht: cmWt: kgIdentifying features:

General appearance:

• HEENT: Normal? Yes/No
• Normal colour vision? Yes/No
• Audiometry:
  • Rt. Normal? Yes/No
  • Lt. Normal? Yes/No

• SKIN:
  • Rash? Yes/No
  • Infection? Yes/No
  • Parasites? Yes/No
  • Lymph glands normal? Yes/No
  • Breasts normal? Yes/No
• RESP:
  • Any chest scars or deformity? Yes/No
  • Chest auscultation normal? Yes/No
  • Any adventitious sounds? Yes/No
  • Current chest X-ray normal? Yes/No/Not Done:Footnote ^*
• CARDIOVASCULAR:
  • BP:   / 
  • Pulse:   / min.
  • Peripheral pulses and circulation normal? Yes/No
  • Normal apex beat? Yes/No
  • Normal heart sounds? Yes/No
  • Murmurs present? Yes/No
  • ECG normal? Yes/No
  • Exercise tolerance test (eg. Ruffier test) normal? Yes/No
• ABDOMEN:
  • Organomegaly? Yes/No
  • Masses present? Yes/No
  • Herniae present? Yes/No
  • Genitourinary system normal? Yes/No
  • Rectal normal? Yes/No
• MUSCULO-SKELETAL:
  • Spine normal? Yes/No
  • Limbs and joints normal? Yes/No
• CNS:
  • Power & tone of limbs normal? Yes/No
  • Normal sensation to pinprick? Yes/No
  • Light touch? Yes/No
  • Temperature? Yes/No
  • Vibration? Yes/No
  • Proprioception normal? Yes/No
  • Cranial nerves normal? Yes/No

  Reflexes	BJ	TJ	SJ	KJ	AJ	Abdo.	Plantar Clonus
  Right
  Left

  • Cerebellar function normal? Yes/No
  • Vestibular function normal? Yes/No
  • Rombergism present? Yes/No
  • Nystagmus present? Yes/No

LAB. INVESTIGATIONS:

• Hb: g/dL
• HCT:
• Sickle cell trait absent? Yes/NoFootnote ^* (initial medical examination)

  • Return to footnote ^*At the discretion of the examining doctor

• Blood group: BUN: Footnote ^* Creatinine: Footnote ^* Other

Urine PH:

Urine free of: albumin? Yes/No

sugar? Yes/No

protein? Yes/No

blood? Yes/No

Comment on any abnormalities detected:

Is the candidate free from physical defect and disease? Yes/No

Has the candidate the physique for prolonged exertion? Yes/No

Is the candidate fit for work in all climates if inoculations are up-to-date? Yes/No

Is the candidate unfit permanently? Yes/No

• Is the candidate unfit temporarily? Yes/No Date for next examination:
• Is the candidate fit with restrictions? Yes/No Specify:

Name and address of examining doctor:

Signed: Date: Place:

Supervisor’s or Pilot’s Medical Examination Record — Part II

To be completed by the candidate in ballpoint pen. Circle correct answer. If in doubt, ask the advice of the examining doctor.

• (a) 

  Family name: First name(s): Birth date:

  S.I.N.: Provincial Health No.:

• (b) 

  Have you had a pilot’s medical examination before? Yes/NoIf yes, when? Where?
• (c) 

  Date and place of any X-ray examinations:
• (d) 

  Give details of vaccinations:
• (e) 

  Do you have, or have you ever had or been treated for, any of the following medical conditions?

  • • 1 Asthma

  • • 2 Hay fever or allergies

  • • 3 Allergy to drugs/medications

  • • 4 Pneumonia or pleurisy

  • • 5 Bronchitis or other lung diseases

  • • 6 Tuberculosis

  • • 7 Sinus trouble

  • • 8 Ear disease

  • • 9 High blood pressure

  • • 10 Rheumatic fever

  • • 11 Heart disease or murmur

  • • 12 Chest pain or palpitations

  • • 13 Bleeding tendency

  • • 14 Skin diseases

  • • 15 Diabetes

  • • 16 Tropical diseases

  • • 17 Fits, blackouts or epilepsy

  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • • 18 Dizziness, loss of balance

  • • 19 Head injury or concussion

  • • 20 Stroke or paralysis

  • • 21 Severe headache or migraine

  • • 22 Nervous breakdown or mental illnesses

  • • 23 Eye disorders

  • • 24 Stomach/duodenal/peptic ulcer

  • • 25 Gall bladder disorder

  • • 26 Diarrhea or bowel disease

  • • 27 Jaundice or hepatitis

  • • 28 Kidney or bladder disease

  • • 29 Bone/joint disease or injury

  • • 30 Back injury or chronic back pain

  • • 31 Other serious illness or injury

  • • 32 Motion sickness

  • • 33 Varicose veins

  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No

  Give details of any positive (Yes) answers, including dates:

  

  

• (f) 

  Give date and place of any hospital admissions or operations:

  

• (g) 

  Have you been under medical treatment during the past year? Yes/NoIf yes, for what?
• (h) 

  Are you taking, or have you ever taken, any medicines or drugs? Yes/NoIf yes, specify:

  

• (i) 

  How much do you smoke? /day How much do you drink? /week Have you ever suffered from any health problems related to mind-altering, “street” or addictive drugs? Yes/NoIf yes, give details:

  

I (name), , of (address) , declare that all of the above information is true to the best of my knowledge and I give my permission for this information to be communicated to other doctors concerned with my well-being.

Signed : Date: Place:

Doctor’s Remarks:

Candidate’s logbook inspected? Yes/NoSigned: M.D

If “no”, state reason: Dated: