BASMU 1				Medical  in Confidence	Name:……………………………..
Revised  nov 2014 ah				(when completed)		Post Title:…………………………
								Post Ref:…………………………..
British Antarctic Survey
Polar Service Application Medical Form

Directions for Applicants:
•	Please first read the guidance notes below.
•	Enter your name and the job for which you are applying in the box in the top right hand corner of this page.
•	Consider the information given on  page 3 and 4 which details medical conditions that may preclude Polar Service.
•	Complete side 2 (overleaf), place in the envelope provided and return with your application 

Guidance Notes:

1.	These notes introduce the medical requirements for Polar service , and serve as the first level of the medical screening process.
2.	It is advisable for your to read form BASMU 2 to understand the work of BASMU and the limitations of medical facilities in remote polar locations.
3.	Obviously even the most thorough medical screening cannot prevent undetectable or unexpected ill health, but the process of screening which you will be expected to undergo will try to confirm your fitness before you leave UK, thus protecting you and your colleagues.
4.	FAILURE TO DISCLOSE A MEDICAL PROBLEM DURING SCREENING MAY PUT YOUR LIFE AND THAT OF OTHERS AT RISK. We therefore ask for your complete honesty when undergoing screening.   
5.	There are certain conditions which will preclude your Polar service, but this is uncommon. Please do not conceal any medical condition at all, even if it seems trivial. Conditions which may recur should be recorded even if you are completely well at the moment.  Allow the experts from BASMU to guide you and decide whether you are fit.   Potential problems can often be solved by frank and open discussion and BASMU will work with you to try to find ways around medical problems where possible.
Should you be selected by BAS or by your employer for a Polar trip, further screening will be needed. This will include a Medical questionnaire and examination by a doctor and possibly relevant investigations. 
6.	We invite you to share the responsibility with us in determining your fitness and ask you to complete the form carefully and truthfully.  In the event of any query, one of the BASMU staff may contact you directly or ask for permission to approach your doctor for further details.

POLAR  SERVICE APPLICATION MEDICAL FORM.

Surname:  ________________________________________    Date of Birth: __________

Forenames:________________________________________________ Age: ___________

Daytime contact telephone number:  ___________________________________________

E Mail address_____________________________________________________________

1.  Please list, with approximate date, all significant illnesses, injuries, operations or other medical problems you have had.  Significant illnesses are those which require more than a couple of weeks off work, OR have required investigation or treatment in hospital, OR have required treatment from your GP or other professional for longer than 2 weeks.   If there are any lasting consequences of these, (permanent symptoms, need for ongoing  treatment, or you have been told it could recur), please give brief details.

(continue on a separate sheet if necessary).
2. Please answer all the following questions.  If you answer “yes” to any of them, please give brief details.
•	Have you consulted a doctor in the last year ?			Yes		No

•	Have you any medical disorder at present ?			Yes 		No

•	Are you taking any tablets, drugs or medicines at present?		Yes		No

•	Have you ever been turned down for life insurance		Yes		No
on medical grounds?

•	Are you aware of ANY circumstances regarding your health which might compromise your ability to do the job for which you are applying, or which might endanger yourself or others ON DEPLOYMENT?
      (see appendix for details of some “problem” conditions)		Yes		No

Declaration:
•	I declare that the information I have given is true to the best of my belief.

Signed_________________________________		Date____________________

A guide to conditions that may cause concern

Conditions that will usually preclude service	Conditions which may preclude service.

Cardiac (Heart)  and circulation problems
Angina & Heart Attacks. *					
Leaky Heart valves & Rheumatic Fever			Previous Heart Surgery*
Uncontrolled High Blood Pressure				
Heart Rhythm Abnormalities	                                	Treated abnormal rhythms*.
Heart Failure						Severe varicose veins
Arterial Disease						Previous Frostbite*
							Severe Reynaud’s disease*
							Previous leg thrombosis*.
							Previous clot on the lung*.
Respiratory (chest) problems
Recurrent “burst” lung (pneumothorax)*			Single episode of pneumothorax*
							History of  moderate or severe Asthma*
Cold induced asthma*					
Chronic Bronchitis or emphysema*
Active Tuberculosis

Gastrointestinal problems	
Active stomach / duodenal  ulcer				History of these ulcers*
Liver Disease						
Pancreatitis 						Previous exploratory abdominal surgery*
Hernia* Untreated)					Severe piles*
Recurrent (inflammatory) bowel disease*

Genito- urinary problems
Recurrent Kidney Stones					Renal colic*
Kidney failure						Recurrent kidney infections*

						 
Neurological Conditions
Epilepsy or fits (on treatment)				Previous fits clear for > 3 years*
Brain Haemorrhage in past* (non  traumatic)			Previous brain surgery*
Unexplained episodes of loss of consciousness		Severe  ME*
					
Degenerative N.M. conditions							
Significant Neuro Deficit secondary							
to Trauma						

Metabolic Conditions
Most diabetes						Mild type II diabetes if well  
							controlled (exceptional)*
							Other “endocrine disorder”*
Cushing’s Disease					Thyroid disease
Addison’s Disease
Obesity (severe)* BMI >35

Musculoskeletal conditions **
Untreated Slipped disc*					Recurrent back pain*	
Lower Limb Amputation*					Severe knee problems*
Recurrent dislocations *(untreated)				Unstable joint*
Rheumatoid Arthritis*					Frequent Gout*
Ankylosing Spondylitis*					

Cancer and Haematological Disorders
Most cancers	Treated cancer with low risk of  recurrence*
Clotting or bleeding disorders
Warfarin Medication					Treated leukaemia*
Bone marrow disease					Treated Hodgkin’s disease*

Gynaecological conditions
Current Pregnancy					Pelvic inflammatory Disease*
							Ovarian disease.*

Dermatological conditions
Blistering Skin diseases					
Severe psoriasis*

Mental Health Problems
Current psychiatric Illness					Depression
Previous severe mental illness				Self harm
Schizophrenia						Previous drug / alcohol problems*
Manic depression
Personality Disorder
Current Drug or alcohol abuse

*  The decision will depend on many different factors and will be made on an individual basis.  With all of these conditions it is much more likely that you would be able to go to the Antarctic for a short summer trip than to overwinter.
** These conditions will be assessed in relation to the capacity to undertake activity/work in the anticipated environment.   

This list is not exhaustive. We would like to invite YOU to share the responsibility for this assessment by declaring ANY medical problem you think may be important.  BASMU staff will always be happy to discuss any medical condition with you with the aim of getting people cleared for Antarctic service.