• Seafarer's Medicals - ENG1 | ML5

    This Pre Appointment Checklist is for ENG1 and ML5

  • NOTICE:
     THIS IS NOT A BOOKING FORM !

    Please fill this form only after you have made a booking on our website.

    You must fill this form prior to your appointment.

    Your clinician will review this form with you again on the day.

     

    If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • When is your appointment?*
     - -
  • Would you like any vaccinations at your appointment?*

  • We are a Yellow Fever center and also provide other vaccines required by seafarers and other travellers.

    Please let us know if we can help you with any vaccines?

  • What vaccinations would you like?
  • Some Seafarers require a reciept for re-imbursenment. Would you like us to prepare a reciept for you on the day?*

  • For Government Guidance on the Seafarers Medical Certification,

    CLICK HERE

  • Seafarer Personal Details

  • Date of Birth*
     - -
  • Gender*
  • Seafarer works solely in the fishing industry*
  • Department*
  • When was your last dental check up?*
     - -
  • Expiry date - Photographic ID Document*
     - -
  • Which Seafarer's Medical do you want to complete?*
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  • Seafarer's Medicals - ENG1

    ENG1 Seafarers Medical Form

  • Seafarer Family Medical History

  • Any Relevant Family History of Medical problems?*

  • Seafarer Medical History

  • Is this the first ENG 1 Seafarer Medical Examination?*
  • If No, tick previous fitness category:
  • Date of Examination
     - -

  • Seafarer Medical History

  • Seafarer's Medicals - ENG1

    ENG1 Seafarers Medical Form

  • Seafarer's Medicals - ENG1

    ENG1 Seafarers Medical Form

  • MEDICAL EXAMINATION OF SEAFARERS CONSENT

    Privacy Notice
    Personal information collected as part of your medical will be entered into the Approved Doctors Information System. Your information is shared with the Maritime and Coastguard Agency (MCA), Chief Medical Advisor, any subsequent Approved Doctors you attend, and MCA administrators if required, for them to fulfil their statutory duties under the Merchant Shipping (Maritime Labour Convention) (Medical Certification) Regulations 2010 or the Merchant Shipping (Work in Fishing Convention (Medical Certification) Regulations 2018, which implement the UK’s international obligations under the Maritime Labour Convention, 2006 and the Work in Fishing Convention, 2007.


    For more information explaining how your information is used, please view our full privacy statement at www.gov.uk/mca


    Consent to examination
    Purpose of the examination: It is a legal requirement for a seafarer or fisherman to hold a valid medical certificate attesting to their medical fitness to perform their duties, taking into account the particular risks associated with working at sea. The medical examination is conducted in accordance with statutory medical standards set by the Secretary of State and overseen by the Maritime and Coastguard Agency. Further details, if required, may be found in MSN 1886 (M+F) and the Approved Doctor’s Manual.

    Nature of the examination:  The Approved Doctor will review your medical history and then examine you. The average duration of the assessment will be 30-45 minutes.

    The standard examination will at a minimum include:
    - Observation of posture, movement and gait
    - Pulse, blood pressure, height, weight, urine test
    - Examination of skin and also leg veins
    - Clinical test of ears and hearing if necessary
    - Clinical test of eyes and eyesight
    - Examination of teeth, gums, mouth and throat
    - Examination of heart, lungs and neurological system
    - Examination of abdomen including checking for hernias
    - Other tests that might be clinically indicated from the history will be explained

     

    It will be necessary for you to be partially undressed to conduct a full examination (down to bra and underpants for females and underpants for males). Privacy and dignity will be of paramount importance at all times and you will be offered a chaperone.

     

    Further information may be required from your GP or specialist prior to making a fitness decision.

     

  • I have read and understood all information above regarding my ENG medical examination. I have been given the opportunity to ask questions and any questions I have asked have been satisfactorily answered. I agree to proceed with the examination.*

  • thank you check icon

    Thank You {givenNames}!

    You are about to submit your questionnaire!

  • Please confirm you have answered all ENG1 questions correctly.*
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  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form
  • This form is for use by the following applicants only. Please tick why you need this form/certificate:*
  • 7. Current ML5 has expired, used for:
  • Date of first BML / RYA endorsement or last revalidation (if applicable)
     - -

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Seafarer Medical History

  • Section 1-Cardiac

  • a) Is the applicant having attacks of angina of effort, or receiving continuous treatment to prevent angina from manifesting itself?*
  • b) Has the applicant had myocardial infarction, unstable angina, or undergone coronary artery bypass surgery or coronary angioplasty?
  • If YES - please answer the following:
  • c) Has the applicant uncontrolled complete heart block?*
  • d) Has a cardiac pacemaker been implanted?*
  • e) Has a cardioverter / defibrillator device been implanted?*
  • f) Is there currently a serious or disabling disturbance of cardiac rhythm, such as atrial fibrillation?*
  • g) Is the applicant in need of medication to prevent paroxysmal arrhythmia?*
  • h) Is there evidence of serious congenital heart disease requiring continuing consultant cardiological review?*
  • i) Is there any history or evidence of heart failure or cardiomyopathy?*
  • j) Has the applicant undergone heart transplant or heart / lung transplant therapy?*
  • k) Has the applicant evidence of an aortic aneurysm that has not been successfully treated by surgery?*
  • n) Is there any history of stroke?*
  • o) Is there any history of Deep Vein Thrombosis?*

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Section 2 – Endocrine and Metabolic

  • Does the applicant have any of the following?:i) Endocrine disease (thyroid, adrenal including Addison's disease, pituitary, ovaries, testes)
  • ii) Diabetes – non insulin, treated by diet alone*
  • iii) Diabetes – non insulin, treated by oral medication*
  • iv) Diabetes – insulin using*

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Section 3 – Nervous System

  • a) Has the applicant had any form of epileptic attack?*
  • ii) Is the applicant still being treated?*
  • b) Is there a history of blackout or impaired consciousness within the last 5 years?*
  • c) Does the applicant have narcolepsy/cataplexy or any obstructive sleep apnoea?*
  • d) Is there a history of, or evidence of any of the conditions listed 1-8 below?.*
  • (1) TIA*
  • (2) Sudden and disabling dizziness/vertigo within the last year with a liability to recur*
  • (3) Subarachnoid haemorrhage*
  • (4) Serious head injury within the last 10 years*
  • (5) Brain tumour, either benign or malignant, primary or secondary*
  • (6) Other brain surgery*
  • (7) Chronic neurological disorders e.g. Parkinson's disease, Multiple Sclerosis*
  • (8) Dementia or cognitive impairment*

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Section 4 – Psychiatric Illness

  • a) Is there a history of, or evidence of any of the conditions listed in 1-6 below?*
  • (1) A psychotic illness in the past 5 years*
  • (2) A neurotic illness (anxiety/depression) in the past 5 years*
  • (3) Persistent alcohol misuse in the past 12 months*
  • (4) Alcohol dependency in the past 3 years*
  • (5) Persistent drug misuse in the past 12 months*
  • (6) Drug dependency in the past 3 years
  • (7) Disorder of personality (clinically recognised)
  • (8) Any other mental health and cognitive disorders

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Section 5 - Sensory

  • Is there deafness that significantly impairs communication by radio or telephone?*

  • Section 6-Malignant Disease

  • a) Does the applicant have any malignant disease likely to impair physical or mental fitness to undertake duties in the foreseeable future?*
  • b) Is there a history of bronchogenic carcinoma or any other malignant tumour (e.g. malignant melanoma) with a significant liability to metastasise cerebrally?*

  • Section 7-Musculoskeletal Limitations

  • a) Does the applicant lack the strength and flexibility needed to: i) perform their normal duties such as mooring and lock operations?*
  • ii) physically assist other people who have fallen overboard or who need to evacuate the vessel in an emergency?*
  • b) If the applicant works at sea, do they lack strength and flexibility to get in and out of a moving life raft? Leave blank if not applicable.*
  • d) Is there currently any disability of the spine, limbs or hands likely to limit duties or safety procedures while working?*
  • e) Has the applicant had a knee/hip replacement or other limb prosthesis?*
  • f) Does the applicant lack sufficient fitness to be responsible for the safety of fare paying passengers (if applicable)?*

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Section 8 – Respiratory System

    Is there a history of, or evidence of any of the following:
  • Sinusitis/Nasal Obstruction*
  • Chronic Bronchitis and/or Emphysema*
  • Pneumothorax*
  • History of severe childhood asthma with any symptoms at all present during the last five years?*
  • Exercise or cold induced asthma?*
  • Mild asthma that requires treatment with bronchodilator reliever inhalers (either alone or to supplement regular use of preventer inhalers) on more than two days a month?*
  • Moderate or severe asthma as an adult?*
  • Any hospital admissions over the last three years (due to asthma), or had oral steroid treatment for asthma during the last three years?*

  • Seafarer's Medicals - ML5

    ML5 Seafarers Medical Form

  • Section 9 - Other Medical Conditions/Additional Information

  • c) Is the applicant taking any medication that can impair safety duties?*
  • d) Is the applicant taking any medication with risk of acute complications?*

  • Seafarer's Medicals - ENG1 | ML5

    This form is for ENG1 and ML5

  • End of Form

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    Please note that after submission, you will not receive an email confirmation.

     

    If you still have further queries, please call and ask to speak to Nick or send us an email. 

     

    Your Excellent Health Service - YEHS 

    25 Harley Street, LONDON, W1G 9QW

    020 4617 6186 | yehs@yourexcellenthealth.org | www.yourexcellenthealth.org

    YEHS! TO EXCELLENT HEALTH Your Excellent Health Service (YEHS) is the trading name for Dr Charlie Easmon Limited (07537353). YEHS is registered with & has been inspected by the Care Quality Commission (CQC): 1-349138322

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