Seafarer Medical Report (ML5) and ML5 Certificate

Seafarer Medical Report (ML5) and ML5 Certificate

MSF 4112 / REV 0818

This form is for use by the following applicants only. Please tick why you need this form/certificate:

TO THE APPLICANT – PLEASE READ THIS INFORMATION CAREFULLY

Please take a form of photographic identification with you to the ML5 Medical examination.

The purpose of the ML5 form is to obtain a factual report of your medical history and present state of health, enabling your doctor to decide on your fitness to navigate safely and undertake emergency duties.

Complete Part A of the form (but do not sign the declaration until you are with the doctor). The Doctor will complete Part B. If Part B shows all ticks in the "NO" boxes without any other remarks then the doctor will complete Part C, the ML5 Medical Certificate.

PART A – PERSONAL DETAILS

Applicant Declaration

I declare that I have checked the details given on the enclosed form and that, to the best of my knowledge and belief, they are correct. I understand that it is a criminal offence if I make a false declaration to obtain certification and can lead to prosecution. I have read the notes on the reverse of the certificate (page 12).

PART B – MEDICAL REPORT

Section 1 – Cardiac

Coronary Heart Disease

a) Is the applicant having attacks of angina of effort, or receiving continuous treatment to prevent angina from manifesting itself? YES NO

b) Has the applicant had myocardial infarction, unstable angina, or undergone coronary artery bypass surgery or coronary angioplasty? YES NO

If YES, what was the nature of the event?

When was the most recent episode?

If the applicant remains on medication, give details

Give details of any continuing symptoms / clinical signs of heart disease

Arrhythmias

c) Has the applicant uncontrolled complete heart block? YES NO

d) Has a cardiac pacemaker been implanted? YES NO

If YES, when did the applicant last attend a pacemaker clinic?

e) Has a cardioverter / defibrillator device been implanted? YES NO

f) Is there currently a serious or disabling disturbance of cardiac rhythm, such as atrial fibrillation? YES NO

g) Is the applicant in need of medication to prevent paroxysmal arrhythmia? YES NO

Other

h) Is there evidence of serious congenital heart disease requiring continuing consultant cardiological review? YES NO

i) Is there any history or evidence of heart failure or cardiomyopathy? YES NO

j) Has the applicant undergone heart transplant or heart / lung transplant therapy? YES NO

k) Has the applicant evidence of an aortic aneurysm that has not been successfully treated by surgery? YES NO

l) Is today’s resting systolic blood pressure 170mm Hg or greater? YES NO

m) Is today’s resting diastolic blood pressure 100mm Hg or greater? YES NO

n) Is there any history of stroke? YES NO

o) Is there any history of Deep Vein Thrombosis? YES NO

Section 2 – Endocrine and Metabolic

i) Endocrine disease (thyroid, adrenal including Addison’s disease, pituitary, ovaries, testes) YES NO

ii) Diabetes – non insulin, treated by diet alone YES NO

iii) Diabetes – non insulin, treated by oral medication YES NO

iv) Diabetes – insulin using YES NO

v) Obesity – BMI over 35 YES NO

Please write BMI here (including BMIs of under 35)

Section 3 – Nervous System

a) Has the applicant had any form of epileptic attack? YES NO

If YES, details of last attack

Is the applicant still being treated? YES NO

If NO, date when treatment ceased

b) Is there a history of blackout or impaired consciousness within the last 5 years? YES NO

c) Does the applicant have narcolepsy/cataplexy or any obstructive sleep apnoea? YES NO

d) History of any listed neurological conditions 1-8? YES NO

Section 4 – Psychiatric Illness

A history of or evidence of any listed mental health or substance conditions? YES NO

Section 5 – Sensory

a) Did the applicant fail the Ishihara colour plate test? YES NO

b) Does the applicant lack the ability to read 6/6 on the Snellen chart at 6 metres distance? YES NO

c) Does the applicant lack the ability to read 6/60 with at least one eye without any visual aid? YES NO

For all applicants record the visual acuity of each eye

d) Has the applicant any defects in their field of vision in either eye? YES NO

e) Is there evidence of any progressive disease in either eye? YES NO

f) Does the applicant have any other eye condition which could limit vision, either now or within the next 5 years? YES NO

Section 6 – Malignant Disease

a) Malignant disease likely to impair physical or mental fitness? YES NO

b) History of bronchogenic carcinoma or any other malignant tumour with significant liability to metastasise cerebrally? YES NO

Section 7 – Musculoskeletal Limitations

a) Does the applicant lack the strength and flexibility needed to perform their normal duties such as mooring and lock operations? YES NO

b) Does the applicant lack strength and flexibility to get in and out of a moving life raft? YES NO

c) Is the applicant’s build likely to interfere with the activities listed above or prevent access to areas of the vessel with limited space? YES NO

d) Is there currently any disability of the spine, limbs or hands likely to limit duties or safety procedures while working? YES NO

e) Has the applicant had a knee/hip replacement or other limb prosthesis? YES NO

f) Does the applicant lack sufficient fitness to be responsible for the safety of fare paying passengers? YES NO

Section 8 – Respiratory System

i) Sinusitis/Nasal Obstruction YES NO

ii) Chronic Bronchitis and/or Emphysema YES NO

iii) Pneumothorax YES NO

iv) Asthma YES NO

a) History of severe childhood asthma with symptoms present during the last five years? YES NO

b) Exercise or cold induced asthma? YES NO

c) Mild asthma requiring bronchodilator reliever inhalers on more than two days a month? YES NO

d) Moderate or severe asthma as an adult? YES NO

e) Any hospital admissions over the last three years, or oral steroid treatment for asthma during the last three years? YES NO

Section 9 – Other Medical Conditions/Additional Information

c) Is the applicant taking any medication that can impair safety duties? YES NO

d) Is the applicant taking any medication with risk of acute complications? YES NO

Section 10 – Declaration by Examining Doctor

Please tick a, b or c as appropriate.

a) There are no ticks in any “YES” box and I have completed the ML5 certificate proforma at PART C and retained a copy.

b) There are ticks in “YES” boxes in Section 1 – 8, so I have not issued the ML5 certificate.

c) There is any other significant medical condition detailed in Section 9, so I have not issued the ML5 certificate

PART C – ML5 Certificate

This is to certify that:

I have assessed the above applicant and all assessment ticks are in the “NO” box (right hand column).

A practical test of capability for current duties has not been carried out.

PART D – MEDICAL REVIEW

Details of vessel

I authorise my doctor(s) and specialist(s) to release reports/medical information about my condition relevant to my fitness, to the MCA Medical Assessor. I authorise the Secretary of State to disclose such relevant medical information as may be necessary to the investigation of my fitness, to my doctor/s and MCA Medical Assessors.

PART E – CONTINUATION BOX