Microsoft word - sea medical longform- medprofsigreq 08-2012.doc
SEA EDUCATION ASSOCIATION Confidential Medical Record Form Please check the appropriate box:
Volunteer Crew Student/Participant SEA Use Only:
Instructions: A physical exam should be completed by a medical professional (MD, PA or NP) within six (6) months prior
to sailing onboard an SEA ship. The exam will be valid for up to two years. You MUST notify SEA of ANY changes in medical condition PRIOR to joining the ship.
Part I - General Information (Completed by Participant)
Name: _________________________________________________________________________ Male________ Female_______ Home Address: _____________________________________________________________________________________________ Cell Phone ( ) ___________________ Email Address: _____________________________ Date of Birth: ___________________ PHYSICIAN:
Name: __________________________________________________________________ Telephone ( ) ____________________ Address: __________________________________________________________________________________________________ EMERGENCY CONTACT: (Person to be notified in case of illness/injury) (Parent/Guardian if under 18 years of age) Name______________________________________________________________ Relationship: ____________________________ Address: __________________________________________________________________________________________________ Cell Phone ( ) ___________________ Other Phone ( ) ___________________ Email: ________________________________ Medical Insurance
We require that you be covered by a sickness and accident policy, which is valid in the USA and foreign countries. Please complete the information below: Insurance Company: _________________________________________________ Policy Number: ___________________________ Subscriber: _________________________________________________________ Relationship to you: ______________________ Insurance Company’s Phone # _________________________________________ Subscriber’s Phone #: ______________________
Swimming Ability: For your safety, it is critical that the captain of the vessel be aware of your swimming/floating ability. Please let us know if you can remain afloat, unassisted, for 30 minutes: Yes: No: Sea Sickness: SEA ships carry meclizine and promethazine for treating seasickness. The captain may make these medications available to participants with the approval of participant’s physician AND parent/guardian (if under 18). Physician: I approve / I do NOT approve (circle one) offering the above medications to this participant for treating seasickness. Physician signature: _________________________________________________________________________________________________________ Parent/Guardian: I approve / I do NOT approve (circle one) offering the above medications to my daughter/son for treating seasickness. Parent/Guardian signature for student under 18): _________________________________________________________________________________ Part II - Medical History (Completed by Participant)
Given the nature of the shipboard environment, it is CRUCIAL that you submit an honest, accurate and complete medical history. With sufficient lead-time, we are able to make certain accommodations for medical conditions onboard ship. If you have had past or current history with ANY of the following, please check the appropriate box, circle and explain below.
Vision problems, eye disease, surgery, color blindness, glaucoma, glasses or
Dizzy spells, fainting, convulsions, seizures, vertigo
Any severe injury to head, chest, or internal organs
Frequent infection of throat, tonsils, sinuses, or ears
Asthma, shortness of breath, chronic cough, bronchitis, tuberculosis, bloody
Back Injury or surgery, ruptured/herniated
Heart condition, irregular heartbeat, heart palpitation, murmurs, pain or angina,
heart attack, congestive heart failure, surgery, pacemaker, poor circulation
Frequent nausea/vomiting, food intolerances/allergies, dietary restrictions,
Gastrointestinal bleeding, Crohn’s Disease, Ulcerative colitis, Gallbladder stone or
surgery, frequent diarrhea or bloody stools
Severe menstrual cramps, frequent abdominal cramps
History of depression, anxiety, hysteria or
Urinary tract infections, painful or frequent urination, bed wetting
Kidney stones or infections, dialysis, transplant
Diabetes, thyroid condition, bleeding problems, or epilepsy
Venereal disease or sexually transmitted disease
Did you check any boxes above? If so, please provide details of the medical condition, both past and present: _________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
(Please attached a piece of paper if additional room is needed for details)
DIETARY RESTRICTION: Have you previously or do you have any dietary allergies, restrictions? Please explain: _________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you follow any of the following diets? VEGAN VEGETARIAN GLUTEN-FREE LACTOSE-FREE PSYCHIATRIC/PSYCHOLOGICAL: Have you previously received or are you currently receiving, a diagnosis or treatment? If so, please print doctor’s name. Also include reason, dates, and medications: ____________________________________________________________________________________________________ PRESCRIPTION MEDICATION(S): If you now take, usually take, or keep with you any prescription medication(s), please specify. Include dosage and purpose: _____________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Authorization
I certify that this health history and all information on it is complete and accurate, and that I am physically and emotionally fit to participate in an extended offshore voyage. In the event I cannot make a decision in an emergency, I hereby authorize the Sea Education Association, Inc. (SEA), its Doctor(s), ship’s Captain or Medical Officer to administer emergency medical treatment and to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for me. I give permission for SEA staff to share information from this form if needed for medical purposes. I understand that I am responsible for notifying SEA immediately of any injury, illness or other medical condition or change to the medical information here provided.
I certify that I am at least 18 years of age. (If not 18, parent/guardian must also sign.) Participant Name (please print): ____________________________________________________________________________________ Participant Signature (required): ________________________________________________________________ Date: ______________ Parent/Guardian Name (if applicable) (please print): ___________________________________________________________________
(Parent/guardian name and signature are required for any Participant who will be less that 18 years of age at the time of sailing)
Part III (Completed by the Physician) PHYSICIAN: Please read carefully. SEA Semester programs involve six-week voyages on research vessels and up to 40 consecutive days on the ocean without a port stop. The 135’ sailing vessels remain at sea far offshore, in areas including the Caribbean, the North Atlantic and Pacific Oceans. SEA Seminar programs involve ten-day sea components.
Medical care essentially is not available. Treatment facilities aboard consist of a modest medicine chest administered by the ship’s Captain. Radio contact may allow the Captain to be guided by a physician ashore. Medical evacuation is not possible except in rare, fortunate circumstances. Participants stand watches around the clock, in an environment that is both physically and emotionally demanding. Seasickness, a common problem, can render oral medication ineffective or impossible. In light of these circumstances, we request a full disclosure of medical problems. Given sufficient lead-time, we frequently can plan to manage a medical condition at sea. If medical problems are discovered at the last minute, it may be necessary for the Participants to leave the ship in the interest of his/her own well-being and that of his/her shipmates. GENERAL HEALTH: Check if within normal range, describe if not. Examination
In addition to your findings during this physical exam, or knowledge or any medical history of this patient, please also comment on specific details of any item in the Medical History on page 2 checked. We are interested in the dates of the condition(s), specific medication(s), effects of not taking the medication(s), and the current status of the condition(s). Please consider the environment described above when making your comments. Full disclosure is critical. Item from page 2: Explanation: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Height (inches): ___________ Weight (lbs): ___________ BP: ____________ Pulse: ______________ General appearance and state of nutrition: ____________________________________________________________________________ Is the participant allergic to any of the following (circle): Medications (penicillin, aspirin, sulfa, etc.) Foods (shellfish, nuts, etc.) Insect bites, Other (wool, feathers, detergents, etc.)
If allergic, what is the reaction? ____________________________________________________________________________________
If the participant has a history of severe allergic reactions, he/she must bring at least 2 Epipen Kits to sea.
Tuberculosis Risk Evaluation: Include skin test and chest x-ray when indicated in your judgment and provide us with the results. With your help, we can monitor risk for our entire shipboard community. No Risk: ______ Risk:______ (attach documentation) Required Immunization: Tetanus Toxoid series. Date of last booster (within 7 years): _________________________________
How long have you known this person? ________________________________________ Do you feel that further diagnostic examination and treatment is indicated? _____________ “I have examined the participant herein described, reviewed his/her health history, and have read the Information for Physician (page 3). It is my opinion that he/she is physically and emotionally fit to participate in the environment described.” NAME of Licensed Physician (please print):_________________________________________________________________________ SIGNATURE of Licensed Physician: ______________________________________________________________________________ Address: _____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Phone #: ___________________________ Email: ________________________________ Date: _______________________________ This form must be returned AS SOON AS POSSIBLE for review prior to joining SEA.
** Anyone sailing onboard an SEA vessel is subject to medical clearance. **
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