Canada Oil and Gas Diving Regulations (SOR/88-600)
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Regulations are current to 2024-11-11
SCHEDULE V(Paragraphs 27(b) and 64(b))
Supervisor’s or Pilot’s Medical Examination Record — Part I
All abnormal findings shall be recorded on the supervisor’s or pilot’s medical examination record.
Family name: First name(s): Birth date: Sex: M/F
Ht: cmWt: kgIdentifying features:
General appearance:
- HEENT: Normal? Yes/No
- Normal colour vision? Yes/No
- Audiometry:
- Rt. Normal? Yes/No
- Lt. Normal? Yes/No
Vision: Distant | Dist. with glasses | Near | Near with glasses | Normal visual fields? | Normal fundi? |
---|---|---|---|---|---|
Right | Yes/No | Yes/No | |||
Left | Yes/No | Yes/No | |||
Both | Yes/No | Yes/No |
- SKIN:
- Rash? Yes/No
- Infection? Yes/No
- Parasites? Yes/No
- Lymph glands normal? Yes/No
- 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/Not Done:Footnote *
- CARDIOVASCULAR:
- BP: /
- Pulse: / min.
- 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
- ABDOMEN:
- Organomegaly? Yes/No
- Masses present? Yes/No
- Herniae present? Yes/No
- Genitourinary system normal? Yes/No
- Rectal normal? Yes/No
- MUSCULO-SKELETAL:
- Spine normal? Yes/No
- Limbs and joints normal? Yes/No
- CNS:
- Power & tone of limbs normal? Yes/No
- Normal sensation to pinprick? Yes/No
- Light touch? Yes/No
- Temperature? Yes/No
- Vibration? Yes/No
- Proprioception normal? Yes/No
- Cranial nerves normal? 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
LAB. INVESTIGATIONS:
- Hb: g/dL
- HCT:
- Sickle cell trait absent? Yes/NoFootnote * (initial medical examination)
Return to footnote *At the discretion of the examining doctor
- 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 unfit permanently? Yes/No
- Is the candidate unfit temporarily? Yes/No Date for next examination:
- Is the candidate fit with restrictions? Yes/No Specify:
Name and address of examining doctor:
Signed: Date: Place:
Supervisor’s or Pilot’s Medical Examination Record — Part II
To be completed by the candidate 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 pilot’s medical examination before? Yes/NoIf yes, when? Where?
- (c)Date and place of any X-ray examinations:
- (d)Give details of vaccinations:
- (e)Do you have, or have you ever had or been treated for, any of the following medical conditions?
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 well-being.
Signed : Date: Place:
Doctor’s Remarks:
Candidate’s logbook inspected? Yes/NoSigned: M.D
If “no”, state reason: Dated:
- Date modified: