Dive Medical/Offshore Risk Assessment

This questionnaire will only be used for purpose of assessing fitness to dive/work offshore. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected FILLED copy will be sent to you after submission. Please print a copy to bring to clinic.

Name (According to NRIC/FIN/Passport)

NRIC/FIN/Passport Number

NUS Staff/Student Number

Occupation

Department/Employer

Date of Birth

Date

Current Age (years)

Gender

MaleFemale

Address

Handphone

Email

example@example.com

Type of Dive

Breathing Gas used

Is this your first time doing a Dive Medical?

Yes - I have not done Dive Medical beforeNo - I have done Dive Medical beforeIf No, when was last Dive Medical?

Frequency of Physical Activity

Type of Physical Activity

Do you smoke cigarettes

NoYes. How many cigarettes per day?

Have you been a smoker in the past?

YesNo

Do you drink alcohol?

YesNo

How many drinks per week (average)

Do you take any tablets or medicines?

NoYes. Specify:

Do you have any allergies?

NoYes. Specify:

Have you ever had any reactions to drugs, medicines or foods?

NoYes. Specify and describe:

SECTION B

Have you ever had, or do you now have or suffer from any of the following:

	No	Yes	Elaborate	Dr Comments
Previous diving medical
COVID
Prescription spectacles
Contact lenses
Eye or visual problem
Dentures or plate
Recent dental procedure
Hay fever
Sinusitis
Nose bleeds
Deafness or ringing noise in ear
Ear infections or discharge from ear
Operation on ear
Other ear, nose or throat problem
Severe motion sickness
Problems with ears or sinuses on flying in aircraft
Severe or frequent headaches
Migraine
Fainting or blackouts
Convulsions, fits or epilepsy
Unconsciousness
Head injury or Concussion
Sleepwalking
Severe depression
Claustrophobia
Mental illness eg anxiety, panic attacks, depression
Heart disease eg hole in heart, coronary heart disease, high cholesterol
Abnormal blood test
Abnormal ECG
Palpitations or irregular heart beats
High blood pressure
Rheumatic fever and heart valve disorders
Pain or discomfort in the chest on exertion
Shortness of breath on exertion
Need to use inhaler or puff
Operation in chest, lungs or heart
Bronchitis or pneumonia
Coughing up blood or phlegm
Chronic or persistant cough
TB
Pneumothorax
Asthma or wheezing
Other chest complaint
Indigestion, acid reflux or peptic ulcer
Vomiting blood or passing red/black stools
Recurrent vomiting or diarrhea
Jaundice, hepatitis or liver disease
Malaria or other tropical disease
Severe loss of weight
Hernia
Back Injury
Significant joint problem or sports injury
Limitation of movement
Fracture
Paralysis or muscle weakness
Kidney or bladder disease
Diabetes mellitis
Sickle cell disease
Bleeding problem or other blood disease
Skin disease
Contagious disease
Operations
Admitted to hospital
Rejected for life insurance
Failed medical examination
Unable to work on medical grounds
Any other illness or health problem
Family history of heart disease
Family history of asthma or chest disease
Females only: Are you pregnant or planning to be in next 6 months?
Females only: Do you have periods which incapacitate you or which reduce your physical/mental performance?

Tetanus Vaccination

NoYes. Date:

Hepatitis B Vaccination

NoYes. Hep B s Antibody titres/date:

SECTION C

Dive Qualifications

Trained in

Approx year of first compressed air dive

Total hours under pressure

How many dives to date

Longest dive

Deepest dive

How many dives in past 12 months

Any Diving injury/Incident in past 12 months

Longest dive in past 12 months

Deepest dive in past 12 months

The above answers were verified with a logbook.

YesNo

SECTION D

Have you ever suffered from:

	Yes	No	Doctors Comments
Ear squeeze
Sinus squeeze
Decompression illness
Headaches during or after dive
Extreme tiredness after dive
Any other diving related problems?

Declaration

I certify that the above information is true and complete to the best of my knowledge.I authorise the clinic to obtain or supply medical information regarding me to other doctors as may be necessary for the medical assessment.I consent to providing my medical information to my employer regarding to my fitness to dive.

Name/NRIC or ID/Signature

Date

Date of Consultation

Date

Time

Hour Minutes

AM/PM Option

PHYSICIAN COMMENTS ON HISTORY

Body Fat%

Height (m)

Weight (kg)

BMI (Satisfactory/Abnormal)

URINE DIPSTICK

NORMALAbnormal. Details:

Waist (cm)

Hip (cm)

Waist Hip Ratio (Satisfactory/Abnormal)

Chest Inspiration (cm)

Chest Expiration (cm)

Visual Acuity

	Uncorrected	Corrected
Right - Far
Left - Far
Right - Near
Left - Near

Colour Perception (Ishihara Chart)

NormalPartial Colour DeficiencyTotal Colour Deficiency

Exercise Tolerance Step Test

RECOVERY HEART RATE AND VO2 MAX

Above tests conducted by:

Tan Siok HoonGoh Sha WeeDr Gregory ChanOther

General Appearance

Blood Pressure (mmHg)

Pulse (/min)

Systemic Review

	Normal	Abnormal	Notes
Head, scalp, face, neck
Opthalmoscopy
Pupils
Eye movements
Visual fields
Nose, septum, airway, sinuses
Mouth, throat, teeth, speech
Ears - external
Tympanic Membrane - right
Tympanic Membrane - left
Eustachian tubes - right
Eustachina tubes - left
Rhines and Webers (if indicated)
Cardiovascular system
Respiratory system
Abdomen
Central nervous system
Skin
Lymph nodes
Posture & gait
Spine
Upper limbs
Lower limbs
Sensation
Cerebellar functions
Emotional & Psychiatric stability
Breast Exam (Females for Offshore Work)

Tendon Reflexes

	Absent	Weak	Mid-range	Brisk	Hyperreflexic
Biceps Right
Biceps Left
Triceps Right
Triceps Left
B/Rad Right
B/Rad Left
Knee Right
Knee Left
Ankle Right
Ankle Left

Peripheral Pulses

Right Dorsalls PedisLeft Dorsalls pedisRight Post TibialLeft Post Tibial

Sharpened Rhomberg's (60s)

Summary of Findings/Investigations

	NA	Satisfactory	Abnormal	Notes & Comments
Physical Examination
Body Fat
Visual Acuity
Color Vision
Step Test (Aerobic Fitness)
Spirometry
Audiometry
Chest Xray
Resting Electrocardiogram
Full Blood Count
HBA1C/ Fasting Glucose
Cholesterol Profile
Tympanometry
Stress ECG
Long Bone Xrays
Other investigations

Other Tests

Nil requiredHEPATITIS B SCREENTETANUS VACCINATIONIndicated. Specify:

Medical Fitness Recommendations

Recreational Diving Certificate required

YesNo

Type of Diving/Work

Certification

Fit to dive/train/workFit to dive/train/work with restrictionPermanently unfitTemporary unfit. Reivew date:Fit to dive/train/work in accordance to Singapore Standards SS511Fit to dive/train/work in accordance to Singapore Standards SS623Fit to be Dive Supervisor (topside) without need for Diving underwaterFit to diveOther

Presence of medical condition that would place the abovementioned at an increased risk of performing his/her work duties. The abovementioned has been informed of the risk:

NoYes

For protection of his/her health & safety, the following is advised:

Validity

1 Year2 YearsOther

Dr Gregory Chan Chung Tsing, PPA(G), PP

MBBS, MMED Occup Med, GDip Geriatric Med, GDip FP Derm, Cert DHM (Adelaide, Toronto), DWD (All hazards)

Senior Specialist Physician, Occupational Medicine

MCR: M06367C

Signature

Date of Certification

Date

Declaration by Candidate

I understand the health risks that I may encounter in diving and how these risks may be reduced. I also understand Medical Practitioner's recommendation herewith is based in part, upon the disclosure of my medical history.I agree to accept any responsibility and liability for health risks associated with my participation in underwater diving, including those that are influenced by change in my health or my failure to disclose any existing or past health condition to Medical Practioner.I consent for medical examiner to discuss with my employer/supervisor about the results of my dive medical.

Candidate's Signature

Date

Dive Medical / Offshore Work Risk Assessment