Canada Oil and Gas Diving Regulations (SOR/88-600)
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Regulations are current to 2023-09-19
SCHEDULE VII(Paragraph 53(b))
Diver’s Medical Examination Record — Part I
All abnormal findings shall be recorded on the diver’s medical examination record.
Family name: First name(s):
Birth date:
Sex: M/F
Ht: cm Wt:
kg
Identifying features:
General appearance:
- HEENT: Normal? Yes/No
- URTI: Normal? Yes/No
- Teeth & gums normal? Yes/No
- Any dentures? Yes/No
- Neck normal? Yes/No
- Sinuses normal? Yes/No
- Dental X-rays normal? Yes/No/Not doneFootnote *
- Normal colour vision? Yes/No
Nasal airway | EAM | Eardrums | Eustacian tube | Audiometry | |
---|---|---|---|---|---|
Rt. normal? | Yes/No | Yes/No | Yes/No | Yes/No | Yes/No |
Lt. normal? | Yes/No | Yes/No | Yes/No | Yes/No | 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
- Skinfold thickness:
- Lt. biceps:
mm
- Lt. triceps:
mm
- Lt. subscapular:
mm
- Lt. sacroiliac:
mm
- 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
- FVC: FEV1/FVC%
%.
- CARDIOVASCULAR:
- BP: /
- Pulse: / min.
- Varicose veins? Yes/No
- 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
- Stress ECG normal? Yes/No/Not done.Footnote +
- ABDOMEN:
- Organomegaly? Yes/No
- Masses present? Yes/No
- Herniae present? Yes/No
- Genitourinary system normal? Yes/No
- Rectal normal? Yes/No
- MUSCULO-SKELETAL
Joint X-rays:Footnote for * Shoulders Hip Knees Rt. normal? Yes/No Yes/No Yes/No Lt. normal? Yes/No Yes/No Yes/No - Spine normal? Yes/No
- Limbs & joints normal? Yes/No
- CNS:
- Power & tone of limbs normal? Yes/No
- Normal sensation to pinprick? Yes/No
- Cranial nerves normal?
- 1
- 2
- 3
- 4
- 5
- 6
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- 7
- 8
- 9
- 10
- 11
- 12
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- 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
- EEG normal? Yes/No/Not DoneFootnote *
- Electronystagmograms normal? Yes/No/Not DoneFootnote *
- LAB. INVESTIGATIONS:
- Hb:
g/dL
- HCT:
- Sickle cell trait absent? Yes/NoFootnote * (initial medical examination)
- 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 permanently unfit to dive? Yes/No
- Is the candidate temporarily unfit to dive? Yes/No Date for next examination:
- Is the candidate fit to dive with restrictions? Yes/No Specify:
- Name and address of examining doctor:
- Signed:
Date:
Place:
Return to footnote *At the discretion of the examining doctor
Return to footnote +Mandatory for divers over 35 years of age
Diver’s Medical Examination Record — Part II
To be completed by the diver 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 commercial diver’s medical examination before? Yes/No
If yes, when?
Where?
When did you first work under pressure?
- (c)Date and place of your last bone and joint X-ray examination:
Other X-ray examinations:
Give details of vaccinations:
- (d)Have you ever had any of the following medical problems?
- 1Skin bends? Yes/No
- 2Limb bends? Yes/No
- 3Spinal or cerebral bends? Yes/No
- 4Pulmonary decompression sickness? Yes/No
- 5Vestibular bends? Yes/No
- 6Pulmonary barotrauma (ruptured lung)? Yes/No
- 7Arterial gas embolism? Yes/No
- 8Problems with compression? Yes/No
- 9Dysbaric osteonecrosis (bone necrosis)? Yes/No
Give details of any positive (yes) answers, including date and number of times the problem has occurred:
- (e)Do you have, or have you ever had or been treated for, any of the following medical conditions?
1 Asthma
2 Hay fever or allergies
3 Allergy to drugs/medications
4 Pneumothorax (collapsed lung)
5 Pneumonia or pleurisy
6 Bronchitis or other lung diseases
7 Tuberculosis
8 Sinus trouble
9 Ear disease
10 Rheumatic fever
11 Heart disease or murmur
12 Chest pain or palpitations
13 Varicose veins
14 Bleeding tendency
15 Skin diseases
16 Diabetes
17 Tropical diseases
18 Fits, blackouts or epilepsy
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
19 Head injury or concussion
20 Stroke or paralysis
21 Severe headache or migraine
22 Nervous breakdown or mental illnesses
23 Eye disorders
24 Stomach/duodenal/peptic ulcer
25 Gall bladder disorder
26 Diarrhea or bowel disease
27 Jaundice or hepatitis
28 Venereal disease
29 Toothache, dental problems
30 Bone/joint disease or injury
31 Back injury or chronic back pain
32 Other serious illness or injury
33 Females: gynaecological disease or pregnancy
34 Motion sickness
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
- Yes/No
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/No
If yes, for what?
- (h)Are you taking, or have you ever taken any medicines or drugs? Yes/No
If 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/No
If 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 welfare.
Signed: Date:
Place:
Doctor’s remarks:
Diver’s logbook inspected? Yes/NoSigned:
M.D.
If “no”, state reason: Dated:
- Date modified: