Service Engineer/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

Date of Birth

Date

Current Age (years)

MaleFemale

Occupation

Employer

Number of years in company

Number of years exposed to loud noise at work

AlwaysSometimesHardly ever

Ear MuffEar plugBothOther

Address

Handphone

Email*

example@example.com

Service EngineerOffshore WorkAttending BOSIET (Basic Offshore Safety Induction and Emergency Training) CourseAttending HUET (Helicopter Underwater Emergency Training)

Type of Physical Activity

NoYes. How many cigarettes per day?

YesNo

How many drinks per week (average)

NoYes. Specify:

NoYes. Specify and describe:

SECTION B

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

Rows	No	Yes	Elaborate	Dr Comments
Previous offshore medical
COVID
Prescription spectacles
Contact lenses
Eye or visual problem
Dentures or plate
Recent dental procedure
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
Heart disease
Abnormal blood test
Abnormal ECG
Palpitations
High blood pressure
Rheumatic fever
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
Bleeding problem or other blood disease
Skin disease
Operations
Admitted to hospital
Rejected for life insurance
Failed medical examination
Unable to work on medical grounds
Family history of heart disease
Family history of asthma or chest disease
Tingling or numbness in hands
Loss of strength in hands
Pain in fingers in cold environment
Any other illness or health problem

NoYes. Date:

NoYes. Hep B s Antibody titres/date:

I certify that the above information is true and complete to the best of my knowledge. I agree to accept any responsibility and liability for health risks associated with my work due to my failure to disclose any existing or past health condition to Medical Practitioner.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 work.

Signature

Date

Date of Consultation

Date

Time

Hour Minutes

AM/PM Option

PHYSICIAN COMMENTS ON HISTORY

Height (m)

Weight (kg)

BMI (Satisfactory/Abnormal)

NORMALAbnormal. Details:

Visual Acuity

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

NormalPartial Colour DeficiencyTotal Colour Deficiency

Audiogram

Rows	500	1 kHz	2 kHz	3 kHZ	4 kHz	6 kHz	8 kHz
Right (AC)
Left (AC)
Right (BC)
Left (BC)

SatisfactoryAbnormalOther

Grip Strength - Right (kg)

Grip Strength - Left (kg)

RECOVERY HEART RATE AND VO2 MAX

Blood Pressure (mmHg)

Pulse (/min)

Systemic Review

Rows	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
Otoscopy

Tendon Reflexes

Rows	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

Right Dorsalls PedisLeft Dorsalls pedisRight Post TibialLeft Post Tibial

Summary of Findings/Investigations

Rows	NA	Satisfactory	Abnormal	Notes & Comments
Physical Examination
Blood Pressure
Visual Acuity
Color Vision
Grip Strength
Hand Arm Vibration Screen
Spirometry
Audiometry
Chest Xray
Resting Electrocardiogram
Full Blood Count
HBA1C/ Fasting Glucose
Cholesterol Profile
Functional Capacity Evaluation
Step Test (Aerobic Fitness)
Stress ECG
Otoscopy
Framingham Risk of Coronary Artery Disease
Other Investigations
Tetanus immunity based on date of vaccination
Hepatitis B immunity
Others

Nil requiredHepatitis B screen - ImmuneHepatitis B screen - Negative. Vaccination advised.Tetanus vaccination given. Valid for 10 years.Indicated. Specify:

Medical Fitness Recommendations

Service Engineer, Shipyard/Ship/RigOffshore WorkBOSIET (Basic Offshore Safety Induction Emergency Training)HUET (Helicopter Underwater Emergency Training)Statutory Medical Examination for Noise (Ministry of Manpower)WORKSHOP TECHNICIANOther

Fit to work/train Service EngineerFit to work/train with restriction Service EngineerPermanently unfit Service EngineerTemporary unfit Service Engineer. Reivew date:Fit to work with NOISEFit to work as Workshop TechnicianOther

NoYes

For protection of his/her health & safety, the following is advised (NOT TO USE):

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

Service Engineer / Offshore Work Risk Assessment