BASMU 3				Medical  in Confidence			
Revised  Nov 2014 AH		           (when completed)			
								
British Antarctic Survey
Polar Service Medical Questionnaire.
(Applicants must read the BASMU 2 information form so they fully understand and accept the nature of the medical service provided by BAS)

Surname:_________________________________________________	Date of Birth:		                                                                                                ---/----/------
Forenames:	__________________________________________        dd / mm / year				       	
Work position/job Title_______________________

ANTICIPATED DEPLOYMENT DETAILS (PLEASE SPECIFY OR CIRCLE APPROPRIATE INFORMATION)

Deployment Location	HALLEY	ROTHERA	SOUTH GEORGIA
     	                             BIRD ISLAND        SIGNY ISLAND	
                   RRS JAMES CLARK ROSS        RRS ERNEST SHACKLETON

			OTHER  please specify_____________________________

Deployment type	SHIP SCIENTIFIC CRUISE		STATION BASED				FIELD BASED	OTHER (please specify___________           

Deployment Length	SUMMER ONLY	OVERWINTER
APPROXIMATE TIME DEPLOYED please specify in  MONTHS_______ or WEEKS_____

Deployment Post/Title :-  _____________________________________________

Employer while deployed	BAS STAFF	OTHER  (please specify___________ 

BASMU USE ONLY . Final Decision on Fitness Category.
M0	Unfit for service in Antarctica / Arctic. Reason…………………………………………………………………………………
M1	In all respects fit for Antarctic / Arctic overwintering service. 
M2	Fit for service re Antarctic / Arctic deep field deployment.
M3	Fit for service re Antarctic / Arctic summer only, ship / coastal stations.  
M4	Fit for service subject to regular medical review (usually annual although shorter intervals may be specified by MO) 
Details…………………………………………………………………………….

 Signature:						Date:

Your Address: _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Post/Zip Code _________________________

Home Telephone: ______________________

Work Telephone: ______________________

Mobile Tel____________________________

E-mail________________________________________________________

Medical History Questionnaire

All questions MUST be answered. Circle or highlight YES or NO, add detail if required. 
The more you tell us about ongoing problems the less we will have to come back to you, or your GP for more information. 
Remember, BASMU tries to work with people who have medical problems to enable deployment if at all possible. We consider each case on its merits and only occasionally have to stop someone deploying on health grounds. 

Have any of your immediate family suffered from the following (please circle):
Diabetes on insulin.			  Heart attack <60yrs.  
Stroke <60yrs.			 Mental health problem 

Have you now, or have you previously had any of the following conditions?

1. 	Cardiovascular.			   	    Details or Doctors Comments
1.1 	 High blood pressure   			    	    YES / NO              	       	                
1.2  	Heart attack / infarction 				    YES / NO	                                                
1.3 	Chest pain, angina or coronary disease                     YES / NO
1.4 	Palpitations or irregular heart beat                            YES / NO
If you have answered YES to 1.2, 1.3 or 1.4, please add detail below at 1.12
1.5 	Rheumatic fever or valve disease                         	    YES NO
1.6	Heart surgery, angiography or operation           	    YES / NO 
1.7 	Investigations for heart problems                 	     YES / NO
1.8   	Anaemia or blood disorder                                        YES/NO
1.9 	Blood clots in legs (thrombosis) or lungs (embolus) YES / NO
1.10 	Varicose veins                                                            YES / NO
1.11 	Ankle swelling (without injury)              	            	     YES / NO
1.12 Answer only if you have cardiac problems.
28.1	
What was the diagnosis given?
When was the event?
Please describe what happened?
What tests did you have?
What were the results?
Are you still on medication for this?
If so what?
Have you made a full recovery?

2. 	Respiratory
2.1 	Asthma   			                               YES / NO		
If YES to 2.1 , please add detail below at 2.9	                  
2.2 	Persistent cough		                               YES / NO
2.3 	Shortness of breath		                               YES / NO
2.4 	Collapsed lung (pneumothorax)                 	     YES / NO
2.5 	Bronchitis or emphysema	                               YES / NO		
2.6 	Pneumonia or pleurisy		                               YES / NO
2.7 	Tuberculosis 			                               YES / NO
2.8 	Other lung disease		                               YES / NO
2.9 Answer only if you have suffered from asthma.
Asthma severity varies enormously from person to person and it is important that we have a clear understanding of how asthma affects you.

At what age was asthma diagnosed?
How often do you have attacks?
Do you use inhalers every day?
If not how often do you need inhalers?
Have you ever required injectable or oral steroid (prednisolone etc) tablets?
Have you ever been in hospital with asthma?
Is your asthma worse in summer or winter?
Is your asthma associated with allergy, cold, or exercise? Which? 
When was your last attack?

3. 	Abdominal or Digestive                                         Details or Doctors Comments
3.1 	Severe, recurrent or persistent indigestion	YES / NO
3.2 	Hiatus hernia or reflux				YES / NO				
3.3 	Stomach or duodenal ulcer			YES / NO
If YES to 3.3 , please add detail below at 3.16
3.4 	Gall bladder disease / gallstones			YES / NO
3.5 	Liver disease or hepatitis			YES / NO
3.6 	Jaundice					YES / NO
3.7 	Appendicitis or appendicectomy			YES / NO
3.8 	Bowel disease or surgery			YES / NO
3.9 	Recurrent or persistent diarrhoea		YES / NO
3.10 	Recurrent or persistent abdominal pain		YES / NO
3.11 	Haemorrhoids (piles)				YES / NO
3.12 	Anal abscess, fissure or fistula			YES / NO
3.13 	Bleeding from bowels or back passage		YES / NO
3.14 	Vomiting blood					YES / NO
3.15 	Unexplained weight loss recently		YES / NO
3.16 Answer only if you have had a stomach or duodenal ulcer.
When was this?
Did you have severe bleeding from this?    Did you make a full recovery?
(Vomiting blood or tarry stools (melaena)) Have you had any recurrence?
Did the ulcer perforate (burst)?
Did you have endoscopy (camera into stomach)?
Did you have surgery?
Did you need a blood transfusion at any stage?
Were you treated for eradication of bacteria which cause ulcers? 
(antibiotics for 4 weeks or so)

4. 	Genito urinary
4.1 	Difficulty passing urine				YES / NO	
4.2 	Bladder infection (cystitis)			YES / NO
4.3 	Kidney infection				YES / NO
4.4 	Kidney stone (renal colic)			YES / NO
4.5 	Other kidney disease				YES / NO
If YES to 4.3 , 4.4  or 4.5 , please add detail below at 4.21
4.6 	Sexually transmitted (venereal) disease		YES / NO
MALES ONLY 
4.7 	Torsion of testis (twisted testicle)		YES / NO
4.8 	Prostatitis					YES / NO
4.9 	Epididymitis (infected testicle)			YES / NO
4.10 	Ulcer on penis					YES / NO
FEMALES ONLY
4.11 	Severe or recurrent thrush			YES / NO
4.12 	Up to date cervical smear test			YES / NO
4.13	Previous abnormal smear			YES / NO
4.14 	Severe period pains				YES / NO
4.15 	Irregular or severe menstrual bleeding		YES / NO
4.16 	Endometriosis					YES / NO
4.17 	Fibroids					YES / NO
4.18 	Pelvic inflammatory disease (infected tube)	YES / NO
4.19 	Ectopic pregnancy				YES / NO
4.20 	Other gynaecological condition			YES / NO
4.21 Answer only if you have had kidney disease or renal colic.
What was the diagnosis?
When did it occur?
How many times have you had problems?
Have you needed surgery for this?
When was your blood last tested for kidney function?
If you know the results please attach them.
Do you have any degree of poor kidney function (renal failure)?
Have you ever needed dialysis?
Have you had a kidney transplant?
Have you been told that you have a high risk for kidney stones?
Do you take any medication?

5  Musculoskeletal                                                       Details or Doctors Comments
5.1 	Fractured / broken bones			YES / NO
5.2	Dislocation or subluxation			YES / NO
If YES to 5.1 or 5.2 , please add detail below at 5.10
5.3 	Joint injuries					YES / NO
5.4 	Injury to neck or back				YES / NO
5.5	Lumbago, sciatica or other back trouble		YES / NO	
If  YES to 5.4 or 5.5 , please add detail below at 5.11
5.6 	Gout						YES / NO
5.7	Arthritis or rheumatism				YES / NO
5.8	Ankylosing spondylitis				YES / NO
 5.9	Overuse or repetitive strain injury		YES / NO	
5.10 Answer only if you have had a fracture or dislocation. For each separate injury please detail. 
Which bone(s) or Joints(s) were affected?
When did it happen?
How was it treated?
What residual symptoms do you have?
What (if any) effect does this have on function of your limbs?
Have you had any recurrence of the same problem, or been told that you are at higher risk (eg shoulder dislocation)?
5.11 Answer only if you have had spinal (neck or back) problems.
When was this?
Which part of your spine was affected?
What symptoms did you have?
Did you have weakness or numbness? If so where.
Did you have any problems with bladder or bowel associated with you spinal problem?
Did you have an MRI or CT scan? Please give the results if you know them.
Did you have surgery? If so what was done?
Have you made a full recovery?  If not detail current problems.
Have you had more than one episode?
Have you been told that you have a higher risk of recurrent problems?

6  Neurological                                                              
6.1 	Epilepsy or fits					YES / NO
6.2 	Narcolepsy, cataplexy or seizure			YES / NO
If YES to 6.1 or 6.2 , please add detail below at 6.8
6.3 	Persistent or recurrent headaches		YES / NO
6.4 	Migraine					YES / NO
6.5 	Fainting or unconscious attacks			YES / NO
6.6 	Dizziness or “turns”				YES / NO
6.7 	Other neurological condition.			
6.8 Answer only if you have had fits, seizures etc
When was this?
What is the diagnosis / type of seizure?
Do you have recurrent problems? If so give details of frequency, type and duration.
Are you on medication for this?
When was your last episode?
Are you allowed to drive?
If currently OK, have you been told that you have a risk of recurrence?

7	Mental Health                                                                 
7.1	Depression 						YES / NO
7.2	Severe or unusual mood swings			YES / NO
7.3	Alcohol or drug dependency. 			YES / NO
7.4	Post-traumatic stress disorder			YES / NO
7.5	Anxiety, panic attacks or phobias			YES / NO
7.6	Personality disorder					YES / NO	
7.7	Other mental illness					YES / NO
7.8	Contact with mental health services			YES / NO
7.9	Self-Harm						YES / NO
If YES to any of the questions in section 7, please add detail at 7.9
7.9  Answer only if you have had mental health problems.
 Living and working, particularly over winter in high latitudes can be a very stressful experience. We need to understand a bit more about your psychological make up. Answers to these questions will of course be kept confidential to the BASMU medical team only.
When did you have the problem?
What was the diagnosis given to you?
Did the problems occur out of the blue, or in response to a life event?   	
How long did it last?
How many episodes have you had?
Do you consider that you are completely recovered?
Did you treatment from your GP?
Did you see a psychiatrist?
Did you have counselling?
Were you on medication?
If so are you still taking it?
Have you had any symptoms in the last year or two?
Have you ever worked or lived in a very isolated community?
Have you lived in a small group other than your family?

8 Ear Nose & Throat	                                                 Details or Doctors Comments
8.1  Perforated (burst) eardrum				YES / NO
8.2  Persistent discharge from ear			YES / NO
8.3  Recurrent sinusitis					YES / NO
8.4  Deafness						YES / NO
8.5  Ringing in the ears or vertigo			YES / NO
8.6  Recurrent tonsillitis or sore throat			YES / NO
8.7  Recurrent or persistent nose bleeds			YES / NO

9. Cancers and Tumours                                            
9.1  Cancer or malignant tumour				YES / NO
9.2  Leukaemia (Cancer of Blood)			YES / NO
9.3  Hodgkins disease or lymphoma			YES / NO
9.4  Skin cancer						YES / NO
9.5  Benign tumour					YES / NO
9.6  Breast disease or ‘lumps’				YES / NO
If you have answered YES to any of the questions in section 9 , please add detail at 9.7
9.7Answer only if you have had cancers or tumours.

Where was your tumour?                               What type was it?
When did it start?                                           What treatment have you had?
When was the last treatment?                         Have you had any recurrence?

10. Eyes
10.1 Glaucoma						YES / NO
10.2 Cataract						YES / NO
10.3 Any other eye condition				YES / NO
10.4 Any eye injury					YES / NO
10.5 Poor sight						YES / NO
10.6 Do you need glasses constantly			YES / NO
10.7 Do you use contact lenses				YES / NO

11 Allergic and Immune Disorders
11.1  Hay fever						YES / NO
11.2  Eczema						YES / NO
11.3  Allergy to food					YES / NO			
11.4  Allergy to medicine				YES / NO
11.5  Allergy to bites or stings				YES / NO
11.6  Anaphylaxis					YES / NO
11.7  Splenectomy					YES / NO
11.8  HIV / AIDS					YES / NO
11.9  Immune suppressing medication			YES / NO
11.10 Organ transplant					YES / NO
 Please give details to what you are allergic, the type and severity of reaction, and any treatment (do you carry an Epi Pen?).

12  Skin Disease                                                            Details or Doctors Comments
12.1 Dermatitis						YES / NO	
12.2 Psoriasis						YES / NO
12.3 Non freezing cold injury				YES / NO
12.4 Frostbite or frostnip 				YES / NO
(Please give details of any previous cold injury)
12.5 Severe burns					YES / NO
12.6 Raynaud’s Disease					YES / NO
12.7 Tendency to cold hands or feet			YES / NO
12.8 Other skin problem				             YES / NO

13. Metabolic and Endocrine
13.1 Diabetes 						YES / NO
If  YES to 13.1 , please add detail at 13.7
13.2  Goitre or thyroid trouble				YES / NO
13.3  Addison’s disease					YES / NO
13.4  Cushing’s disease					YES / NO
13.5  Other endocrine problem				YES / NO
13.6  High cholesterol or lipid				YES / NO
13.7 Answer only if you suffer from diabetes
Do you have Type 1 or Type 2  diabetes?
Do you need insulin injections?
What medication do you take?
How good is your sugar and other diabetic control? Please send your last 6 blood sugar and HbA1C results. Do you also have high cholesterol?
Do you have any eyesight problems with your diabetes?
Do you have any problems with the sensation (feeling) in your legs as a result of your diabetes (peripheral neuropathy)?

14	Miscellaneous Conditions
14.2 Malaria						YES / NO
If YES to 14.2 ,  do you have recurrent attacks?
14.3 Other tropical disease				YES / NO	
If YES to 14.3 give details:

15. How many days absence from work due to sickness or injury have you had in the last two years?

16. Are you currently taking any medication either prescribed by your doctor or bought “over the counter”.  If so what?

17. Give dates of the last time you had these vaccinations if required (consult immunisation list as needed):
17.1 	Tetanus/Diptheria/Polio	
17.3 	Seasonal Flu
17.4 	BCG (Tuberculosis)
17.5 	Hepatitis A
17.6 	Hepatitis B
17.7	MMR ( measles/ mumps/ rubella)
17.8 	Meningitis A&C

18. Have you ever been rejected for employment with the Armed Forces or any other organisation, or have you been discharged on medical grounds.	YES / NO    
If so, give details.

19. Tuberculosis Risk Screening : 

19.1 Have you or anyone in your family ever been treated for TB?   
 YES / NO        If yes, please specify……………………………………………………

19.2 Have you in the last 3 years lived in the same household as anyone who you know to have had tuberculosis (TB)?  
YES / NO         If yes, please specify …………………………………………….

19.3	Have you had in the past year?
•	Cough, especially if blood stained spit produced
•	Unexplained weight loss, lethargy or tiredness

•	Unexplained sweats or fever
YES / NO	
If yes, please specify ……………………………………………………

•	

20. DENTAL STATUS
All BAS staff, visitors and collaborators are required to maintain good dental hygiene and within 6 months  prior to deployment to have visited their own dentist for a check up and treatment if required. No person will be medically cleared for deployment if not dentally fit at point of deployment.
So that BASMU is aware of your dental status and can if necessary contact your dentist in an emergency please complete the following:

Your Dentist’s Name___________________________________________________________

Your Dentist’s telephone Number_________________________________________________

Date of your last visit to your Dentist______________________________________________
 
Summer only staff to provide BASMU 7 dental report form.
Overwintering and Deep Field staff to provide BASMU 8 dental report form.
The above information is vital in a situation where the Base Doctor (who undertakes a 3 day emergency dental techniques course) is the only practitioner available to provide treatment.
BASMU 7 and/or 8 forms should be completed by all BAS staff. Successful new applicants will be asked to complete the relevant dental form before medical clearance for employment is given.

If there are dental issues you wish to highlight, indicate below:-

21. Have you undergone a previous                     22. Have you been the recipient of a
special medical examination for                           blood transfusion since 1 January   
your employment e.g. diver, aircrew,                   1980                YES / NO
seafarer. If YES indicate:
Date:-
Type:-
Pass/Fail

23 .Applicants’GP / Doctor details :-

Name ________________________________________________________________

Surgery Address_________________________________________________________

            ________________________________________________________________  
  E-mail address if known__________________________________________________________    

Tel __________________________	  Fax _____________________________

Declaration:  
•	I declare that the information given relating to my medical examination is true to the best of my belief.   
•	I understand that any wilfully incorrect or misleading statement or omission may render me liable to disqualification from BAS employment, or exclusion from Antarctic Service. 
•	I understand that giving  incorrect information may lead to adverse events affecting my health and the wellbeing and safety of other personnel in the Antarctic / Arctic
•	I agree to keep BASMU informed of my medical status prior to deployment.
•	I understand that the decision on my fitness will be communicated to the BAS Human Resources Department.

Signed …………………………………………….	Dated………………………

BRITISH ANTARCTIC SURVEY
MEDICAL UNIT
Consent Declaration

You are advised to read this before you sign the declaration overleaf, and also read the booklet BASMU2, Medical aspects of living and working in the Antarctic.

Before acceptance for employment or at a later stage during employment with BAS it may be necessary for the BASMU Medical Officer to request a report from your General Practitioner (GP) or another doctor who has been involved in your medical care.

Your written, informed, consent is necessary before the SMO can request any such report.   This consent is overleaf.  However, under the Access to Medical Records Act 1988, you have certain rights of access to any such report which are summarised in the following notes.

1.	You do not have to give your consent, but if you do, you can decide whether you wish to see the report before it is sent to the BAS SMO. This request for access can be made either:-
	-	at the time that you give your consent by signing overleaf.
	-	at a later stage directly to the doctor from whom the report may be requested, before 	this report is returned to BAS SMO.
	If you do not give your consent, the inability to obtain up-to-date medical information may affect decisions made about your employment with BAS.

2.	In the event of a request for a report being necessary and, if you decide that you wish to see any report, then BAS SMO will:

	-	inform you that a request is being made to the doctor

	-	inform the doctor that you wish to see the report before it is sent.

	You will then have 21 days in which to contact the doctor about arrangements for you to see the report.

3.	Whether or not you say that you wish to see the report before it is sent to the BAS SMO, the reporting doctor must allow you to see a copy, upon request, for up to six months after it is supplied.  If you request a copy of any report, the doctor may charge a reasonable fee for this service.

4.	Once you have seen the report, the doctor cannot release it to the BAS SMO without your consent.  You are entitled to write to the doctor requesting amendment of any part of the report which you consider to be incorrect or misleading or to have attached to the report a statement of your views on any part where you and the doctor are not in agreement but which the doctor is not prepared to alter.

5.	The doctor is not obliged to let you see any part of a report if, in his/her opinion, it would be likely to:-

	-	cause serious harm to your physical or mental health, or that of others
	-	indicate the doctor’s intentions towards you
	-	would reveal information on, or the identity of another person who has supplied 	information about you unless that person has consented, or the information relates to,	or has been supplied by a health professional involved in caring for you.

	In such cases the doctor must notify you and you will be limited to seeing any remaining part of the report.  If the whole report is involved, this must not be returned to BAS without your consent.

6.	In the interests of your optimal care and for operational reasons, in the event that a report is requested whilst you are serving overseas, the declaration that you are asked to sign contains your agreement to any such report being supplied without your having sight of it. This does not affect your statutory rights and you may apply within six months to the reporting doctor for a copy.

Declaration & Consent
I hereby authorise the British Antarctic Medical Unit Senior Medical Officer to request at his/her discretion a medical report from my General Practitioner (GP) listed above or other practitioner, and access to information from my medical records held by my GP or other medical attendant.
I have been informed of my statutory rights under Access to Medical Reports Act of 1988.

I am aware of the limitations of medical support and medical facilities in the Antarctic as indicated in the booklet BASMU 2, Medical Aspects of Deployments’ in Polar Regions.
I accept my medical data may be provided to other nations Antarctic/Arctic medical units if my deployment requires me to come under their care/supervision.

(delete as appropriate)
I wish / I do not wish  to see the report before it is supplied to the BAS Medical Unit.  In the event that a report is requested whilst I am serving overseas, I agree to this report being supplied without my having sight of it.

Print Full Name………………………………………….

Signature 	    ............................................................. date…………….

Address               .............................................................

		    .............................................................		    

Date of Birth	    .............................................................