0

Code
All. 02 P 5.02 IO
11 SMS

Corporate Management System

rev.
0

P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Date

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Page 1 of 16

SECTION A - TO BE FILLED IN BY THE APPLICANT

You must fill out this section before you have a medical examination. You must carry a valid identity
document (passport, identity card, driving license).
Voc deve preencher essa seo antes de ter um exame mdico. Voc deve levar um documento de
identidade vlido (passaporte, bilhete de identidade, carta de conduo).
PRIVACY:
Please read carefully for information and guidance. The information contained in this form and
the documents annexed to it will be used for the assessment of physical fitness for work at
sea. This information can be exchanged between the medical examiner and his attending
physician or another physician of a examining commission to assess their eligibility to work at
sea. If you do not get the fitness you and your employer will be notified by this certificate.
PRIVACIDADE:
Por favor, leia com ateno para a informao e orientao. As informaes contidas neste formulrio e os
documentos anexos sero utilizados para a avaliao de aptido
aptido fsica para o trabalho no mar. Esta
informao pode ser trocada entre o mdico legista e seu mdico assistente ou outro mdico de uma
comisso examinadora para avaliar a sua elegibilidade para trabalhar no mar. Se voc no conseguir o
condicionamento fsico
sico que voc e seu empregador ser notificado por este certificado.
SURNAME: .

NAME: .

DATE OF BIRTH: .. / .. / .

PLACE OF BIRTH:
SEX:

PASSPORT/ SEAMAN BOOK Nr

RESIDENCE:
STREET.
CITY: .

PROV: .

STATE: ..

CAP: ...

JOB POSITION ON BOARD:

DEPARTMENT:

POSITION: ..
YES

NO

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Code
All. 02 P 5.02 IO
11 SMS

Corporate Management System

rev.
0

P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Date

Are you healthy at the moment?/ Voc est saudvel neste momento?

Do you drink alcohol? Voc bebe lcool?

If YES how often?

.. / days for week/

week

Se SIM com que frequncia? ........ / Dia para a semana

Are you assuming current medications? Voc est supondo que os medicamentos atuais?
If
YES
what?............................................................................................................................
?...........................................................................................................................................
...............
SE SIM QUAL
Do you have or have had any eyes problems or eyes injury?
Voc tem ou j teve problemas de leso olhos ou os olhos?
NOTE:: If you have glasses or contact lenses, bring them with you at the time of the
examination. Chromatic lenses are not allowed
NOTA: Se voc tiver culos ou lentes de contato, traga-os
traga os com voc no momento do exame.
Lentes cromticas no so permitidos
Have you ever been declared unfit for work at sea?
Voc j foi declarado inapto para o trabalho no mar?
If YES how long and for what reason?
Se sim quanto tempo e por qual
al razo?
Your medical certificate of competency has never been released with restrictions or been
declared unfit?
Seu atestado mdico de competncia nunca foi liberado com restries ou sido declarada
imprpria?
Do you smoke tobacco?
Voc fuma tabaco?
Have you ever smoked in the past?
Alguma vez voc j fumou no passado?

Page
Page 2 of 16

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Code
All. 02 P 5.02 IO
11 SMS

Corporate Management System

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P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Date

Have you ever been absent from work due to illness or injury for more than 14 consecutive
days in the last two years?
Voc j esteve ausente do trabalho por motivo de doena ou acidente por mais de 14 dias
consecutivos, nos ltimos dois anos?
If YES please
se give details..
SE SIM COLOCAR OS DETALHES
Have you ever had surgical treatments?
If YES please give details...
Alguma vez voc j teve tratamentos cirrgicos?
SIM, QUAL?
Have you ever been disembarked sick or repatriated from a ship?
If YES please give details ...
Alguma vez voc j desembarcaram doentes ou repatriados a partir de um navio?
SE SIM QUAL?
Have you ever had before any of the following symptoms or illnesses?
Alguma vez voc j tinha antes de qualquer um dos seguintes sintomas ou doenas?
Mark with an X only positive responses
SOMENTE POSITIVO MARQUE COM O X
Anxiety or depression
Ansiedade ou depresso

Hernia
hrnia

Migraine or persistent headache

Enxaqueca ou dor de cabea persistente

Recent changes in weight

As recentes mudanas no peso

Epilepsy or convulsions
Epilepsia ou convulses

Asthma
asma

Poliomyelitis or other paralysis

A poliomielite ou paralisia outro

Bronchitis or emphysema
Bronquite ou enfisema

Attacks of unconsciousness or weakness

Ataques de inconscincia ou fraqueza

Tuberculosis
tuberculose

Dizziness
tontura

Dyspnea
dispnia

Hypertension
hipertenso

Persistent cough
tosse persistente

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All. 02 P 5.02 IO
11 SMS

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rev.
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P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Date

Page
Page 4 of 16

Heart disease or venous diseases

Doenas cardacas ou doenas venosas

Pneumothorax
pneomonia

Heart surgery
A cirurgia cardaca

Other lung diseases

Outras doenas pulmonares

Anemia or other blood disease

Anemia ou outras doenas do sangue

Abnormal chest radiograph

Radiografia de trax anormal

Swelling of the ankles

Inchao dos tornozelos

Bladder infections
As infeces da bexiga

Heart palpitations
palpitaes cardacas

Kidney disease or kidney stones

Doena renal ou pedras nos rins

Varicose veins
varizes

Difficulty in urinating
Dificuldade em urinar

Abnormal bleeding
sangramento anormal

Any abnormalities in the urine

Quaisquer anomalias na urina

Rheumatic fever
febre reumtica

Sexually Transmitted Diseases

Doenas Sexualmente Transmissveis

Liver disease (including jaundice or hepatitis)

Doena heptica (incluindo ictercia ou
hepatite)

Back pain, sciatica or other back problems

Dor nas costas, dor citica ou outros
problemas nas costas

Disease or ulcers of the stomach or duodenum

Doena ou de lceras do estmago ou do
duodeno

Any kind of arthritis

Qualquer tipo de artrite

Intermittent abdominal pain / dyspepsia

Dor abdominal intermitente / dispepsia

Herniated disc or neck pain

Hrnia de disco ou dor de pescoo

Appendicitis
apendicite

Repeated injuries and sprains, tendonitis

Leses e entorses, tendinites repetidas

Cholecystitis
colecistite

Fractures of bones
Fraturas de ossos
Gout
Doena de artilulaoes

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Code
All. 02 P 5.02 IO
11 SMS

Corporate Management System

rev.
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P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Date

Page
Page 5 of 16

Bowel disease
Hemorrhoids
hemorridas

Ear infections or eardrum perforations

As infeces de ouvido ou perfuraes do
tmpano

Please provide in the space below any disorder, illness or injury sustained or not included in the above

Por favor, fornea no espao abaixo de qualquer desordem, doena ou leso sofrida ou
no includo no acima
Por favor, fornea no espao abaixo de qualquer desordem, doena ou leso sofrida ou no includo no
acima
list:

Tinnitus and balance disorders

Zumbido e distrbios do equilbrio

Allergies including hay fever

Alergias, incluindo a febre do feno

Deafness
surdez

Any abnormality of the immune system

Qualquer anomalia do sistema imunolgico

Problems, nasal and sinus

Problema, nasal e sinisite

Any allergic reaction to serums, drugs or

medication
Uma reaco alrgica a soros, drogas ou
medicamentos

Hoarsely persistent or frequent sore throat

Rouca persistente ou freqente dor de
garganta

Allergic reactions to anesthetics and vaccines

As reaes alrgicas aos anestsicos e vacinas

Goiter or thyroid disease

doena da tireide

Diseases such as malaria, amoebiasis, typhoid

Doenas como a malria, amebase, febre
tifide

All forms of neoplasia

Todas as formas de neoplasia/cancer

Severe problems with their teeth or gums

(including wisdom teeth)
Graves problemas com seus dentes ou
gengivas (incluindo os dentes do siso)

Insulin-dependent diabetes
Diabetes mellitus insulino-dependente
dependente

Oral surgery
cirurgia oral

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Code
All. 02 P 5.02 IO
11 SMS

Corporate Management System

rev.
0

P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Dermatitis / eczema / rashes

Dermatite / eczema / erupo

Date

Page
Page 6 of 16

Any problem obstetrical or gynecological

Qualquer problema obsttrico ou
ginecolgico
Are you pregnant?
Voc est grvida?

Please provide in the space below any disorder, illness or injury sustained or not included in the above list:
Por favor, fornea no espao abaixo de qualquer desordem, doena ou leso sofrida ou no includo na lista
acima

The following document should be signed in the presence of the examining physician.

Are you aware of any circumstances regarding your health that may interfere with the
performance of work related to your position / occupation?
If YES please provide details:
Voc est ciente de todas as circunstncias em relao a sua sade que possam interferir
com o desempenho do trabalho relacionado com a sua posio / ocupao?
Em caso afirmativo, fornecer detalhes

YES

NO

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Code
All. 02 P 5.02 IO
11 SMS

Corporate Management System

rev.
0

P5 CORPORATE HUMAN RESOURCES

Medical Examination Form (Eng)

02/07/2013

Date

Page
Page 7 of 16

DECLARATION

Date: .

I, the undersigned declare that to the best of my knowledge,

my personal statement is true and correct.
Eu, abaixo assinado ............................................................... declarar que ao melhor de meu conhecimento,
a minha declarao pessoal verdadeiro e correto.
Signature of candidate
_________________________
Authorities which disclose medical information:
If as a result of this or following visits, with the aim of assessing the state of my health requirements for
work at sea, the doctor requests information from my doctor or to another specialist, I hereby grant
permission to obtain information
ormation from:
Se, como resultado desta ou aps visitas, com o objetivo de avaliar o estado dos meus requisitos de sade
para o trabalho no mar, o mdico solicita informaes do meu mdico ou a outro especialista, que concede
permisso para obter informaes
es a partir de:

Address and phone number

Dr.
.............................................................

Address and phone number

Dr.
.............................................................

Address and phone number

Dr.
.............................................................

Date:

Signature of candidate