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

Diver’s Medical Examination Record — Part I

All abnormal findings shall be recorded on the diver’s medical examination record.

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

Ht: cm Wt: kg Identifying features:

General appearance:

• HEENT: Normal? Yes/No
• URTI: Normal? Yes/No
• Teeth & gums normal? Yes/No
• Any dentures? Yes/No
• Neck normal? Yes/No
• Sinuses normal? Yes/No
• Dental X-rays normal? Yes/No/Not doneFootnote ^*
• Normal colour vision? Yes/No

• SKIN:
  • Rash? Yes/No
  • Infection? Yes/No
  • Parasites? Yes/No
  • Lymph glands normal? Yes/No
  • Skinfold thickness:
    • Lt. biceps: mm
    • Lt. triceps: mm
    • Lt. subscapular: mm
    • Lt. sacroiliac: mm
  • 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
  • FVC: FEV₁/FVC%%.
• CARDIOVASCULAR:
  • BP:   / 
  • Pulse:   / min.
  • Varicose veins? Yes/No
  • 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
  • Stress ECG normal? Yes/No/Not done.Footnote ⁺
• ABDOMEN:
  • Organomegaly? Yes/No
  • Masses present? Yes/No
  • Herniae present? Yes/No
  • Genitourinary system normal? Yes/No
  • Rectal normal? Yes/No
• MUSCULO-SKELETAL

  Joint X-rays:Footnote for *	Shoulders	Hip	Knees
  Rt. normal?	Yes/No	Yes/No	Yes/No
  Lt. normal?	Yes/No	Yes/No	Yes/No

  • Spine normal? Yes/No
  • Limbs & joints normal? Yes/No
• CNS:
  • Power & tone of limbs normal? Yes/No
  • Normal sensation to pinprick? Yes/No

  • Cranial nerves normal?
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • Yes/No
  • 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
  • EEG normal? Yes/No/Not DoneFootnote ^*
  • Electronystagmograms normal? Yes/No/Not DoneFootnote ^*
• LAB. INVESTIGATIONS:
  • Hb: g/dL
  • HCT:
  • Sickle cell trait absent? Yes/NoFootnote ^* (initial medical examination)
  • 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 permanently unfit to dive? Yes/No
• Is the candidate temporarily unfit to dive? Yes/No Date for next examination:
• Is the candidate fit to dive with restrictions? Yes/No Specify:

• Name and address of examining doctor:
  • Signed: Date: Place:

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

• Return to footnote ⁺Mandatory for divers over 35 years of age

Diver’s Medical Examination Record — Part II

To be completed by the diver 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 commercial diver’s medical examination before? Yes/NoIf yes, when? Where?

  When did you first work under pressure?

• (c) 

  Date and place of your last bone and joint X-ray examination:

  Other X-ray examinations: Give details of vaccinations:

• (d) 

  Have you ever had any of the following medical problems?
  • 1 

    Skin bends? Yes/No
  • 2 

    Limb bends? Yes/No
  • 3 

    Spinal or cerebral bends? Yes/No
  • 4 

    Pulmonary decompression sickness? Yes/No
  • 5 

    Vestibular bends? Yes/No
  • 6 

    Pulmonary barotrauma (ruptured lung)? Yes/No
  • 7 

    Arterial gas embolism? Yes/No
  • 8 

    Problems with compression? Yes/No
  • 9 

    Dysbaric osteonecrosis (bone necrosis)? Yes/No

  Give details of any positive (yes) answers, including date and number of times the problem has occurred:

  

• (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 Pneumothorax (collapsed lung)

  • • 5 Pneumonia or pleurisy

  • • 6 Bronchitis or other lung diseases

  • • 7 Tuberculosis

  • • 8 Sinus trouble

  • • 9 Ear disease

  • • 10 Rheumatic fever

  • • 11 Heart disease or murmur

  • • 12 Chest pain or palpitations

  • • 13 Varicose veins

  • • 14 Bleeding tendency

  • • 15 Skin diseases

  • • 16 Diabetes

  • • 17 Tropical diseases

  • • 18 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
  • Yes/No
  • • 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 Venereal disease

  • • 29 Toothache, dental problems

  • • 30 Bone/joint disease or injury

  • • 31 Back injury or chronic back pain

  • • 32 Other serious illness or injury

  • • 33 Females: gynaecological disease or pregnancy

  • • 34 Motion sickness

  • 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 welfare.

Signed: Date: Place:

Doctor’s remarks:

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

If “no”, state reason: Dated: