Name *

First

Last

Email *

Date of birth *

Age *

Passport/driving licence number. *

Employer *

Offshore job title *

GP NAME/PRACTICE *

Date of last offshore medical *

Outcome of last medical *

• Pass - unrestricted
• Pass - time restricted
• Pass - destination restricted
• Fail

Current offshore installation *

Core crew *

• Yes
• No

Smoking status *

• Never smoker
• Ex-smoker
• Smoker

Number of units of alcohol per week *

Have you ever been exposed to any known occupational hazard such as noise, radiation, dusts, asbestos, chemicals or lead? *

• Yes
• No

Do you use protective clothing? *

• Yes
• No

Do you use safety glasses? *

• Yes
• No

Do you use hearing protection? *

• Yes
• No

Have you ever developed a medical condition in connection with your occupation? *

• Yes
• No

Have you ever suffered an industrial injury? *

• Yes
• No

Have you ever had any previous audiometric screening (hearing test)? *

• Yes - normal
• Yes - abnormal
• No

Have you ever had lung function testing? *

• Yes -normal
• Yes - abnormal
• No

Have you ever been rejected from employement on medical grounds? *

• Yes
• No

Have you ever received compensation or is there any industrial claim pending? *

• Yes
• No

Have you ever been medevaced from an offshore installation? *

• Yes
• No

Do you or have have you ever been diagnosed as suffering from any of the following? *

• Chest pain/heart pain
• High blood pressure
• Stroke
• Asthma
• Epilepsy
• Diabetes
• Peptic ulcer disease
• Kidney disease
• Psychiatric disorder
• TB
• Cancer
• Allergies
• NONE OF THE ABOVE

If you have checked any of the conditions above, please elaborate here.

Do any of your immediate family (parents/brothers/sisters) have a history of any of the above conditions? *

• Yes
• No

Do you currently have any of the following? *

• Backache/joint/muscular pain
• Hernia/rupture
• Visual impairment
• Perforated eardrum/discharge from ear
• Recurrent indigestion
• Jaundice/hepatitis/gallbladder disease
• Change in bowel habit
• Blood in stools/haemorrhoids/piles
• Shortness of breath/coughing up blood
• Recurrent bronchitis/pneumonia/COPD
• Blood in urine/kidney complications/stones
• Headache/migraine/dizziness
• NONE OF THE ABOVE

Please list any medications here, including over-the-counter. If none, please type n/a. *

Has there been any change in your health since your last medical? If so, please detail here. If not please type n/a *

Are you seeing your GP regularly for any reason? *

Have you suffered from any of the following? *

• Chest pain
• Second Choice
• Third Choice
• Palpitations
• Joint pain/swelling
• Recurrent pain in your back
• None of the above

Have you ever been diagnosed with any of the following? *

• Coronary heart disease
• Angina
• Heart attack
• Aortic aneurysm
• Heart failure
• High blood pressure
• Cardiac arrhythmia
• Cardiomyopathy
• Osteoarthritis
• Rheumatoid arthritis
• Connective tissue disease
• Other bone or joint disease
• None of the above

Have you ever undergone any of the following? *

• Coronary artery bypass graft
• Coronary angiogram
• Pacemaker insertion
• Implanted cardia defibrillator
• Joint replacement/joint surgery
• Non of the above

Submit