BASMU4				Medical  in Confidence			
Revised  nov 2014. ah			(when completed)			
										
British Antarctic Survey
Polar Service Medical Examination Record.

PERSONAL DETAILS

Surname______________________________   Date of Birth (dd/mm/yyyy)_______________   

Forenames_____________________________  Post Title___________________________________

				
To the Examining Doctor.
Guidance notes are available. If you are unfamiliar with BASMU requirements please read these before completing the form. The Polar regions are a unique environment which poses very different medical challenges from anywhere else. Our criteria are therefore in some respects different from more usual screening examinations. Please complete ALL sections below.

		Date of form completion (dd/mm/yyyy)                             
1.General
Please discuss the BASMU 3 Questionnaire with the candidate, and summarise any significant Past Medical History.   Please note specifically any allergic reactions, any adverse effects of medication, any general anaesthesia/ surgery.
Details:

Is the person registered with your practice?		Yes / No

If so is his / her general health good?			Yes / No

Is there any significant Family History?		Yes / No
Details:

Smoking Habits

Alcohol (Units / Week)

2.Vital statistics

Height	    ___  cm		Weight	     ___  kg		 BMI	____		

Waist circumference	____cm           Hip  circumference	____cm

If BMI is greater than 35 then the person is likely to be UNFIT for Antarctic Service.  If their build suggests that this is due to muscle bulk rather than obesity please note this here, and continue with the examination.  If the raised BMI appears to be due to obesity alone, there is no need to continue further.  

	
3.Vital signs

Resting Pulse Rate ____ b.p.m.		Blood Pressure ____	/ ____	mm.Hg

Pulse Rhythm	  _________			Respiratory Rate____

4.Vision

Please note:
Visual conditions / restrictions		Normal   Abnormal

Colour Vision	 / Ishihara			Normal   Abnormal 

Comment:

5.Examination
For Each of the following questions please enter one of the following codes:	
Within Normal Limits		
Abnormal		X	
Not Examined	--	
			
Please give details of abnormal findings	
		Code	Details	
1	General Appearance			
				
2	Head and Neck			
				
3	Eyes			
				
4	Ears			
				
5	Nose			
				
6	Mouth and Pharynx			
				
7	Thyroid			
				
8	Lymph Nodes			
				
9	Chest and Lungs			
				
10	Breasts			
	(if Indicated)			
11	Heart sounds			
				
12	Murmers			
				
13	Abdomen			
				
14	Organomegaly			
				
15	Hernial Orifices			
				
16	Rectal Examination			
	(if clinically indicated)			

17	Genitalia			
	(if indicated)			
18	Spine			
				
19	Lower limbs			
				
	Peripheral pulses			
	Varicose veins			
				
20	Upper Limbs			
				
	Raynauds			
				
21	Skin			
	Previous Cold Injury			
	Scars			
	Tattoos			
	Identifying Marks			
				
22	neurological status			
				
26	Mental Health status			
	Mood			
	Affect			
				
27	Gynaecological Examination		
	(if indicated)			

Please describe any other abnormal Findings on Examination?

6. Investigations

Urinanalysis results:

ECG required for patients at first BASMU medical when 50 years of age and over or if clinically indicated.
Attach ECG to papers when forwarding.

Chest X-Ray required   only where clinically indicated. Attach results or forward when available.

Blood Group if known…………………………...
(If not know we would encourage staff to become blood donors within their own national scheme, gaining this information and providing a valuable service to society)

For Over wintering staff only 
Blood group and donor screening.
If you have recent results available then please record these below. Otherwise please arrange for blood to be taken. In UK this should be sent to the BTS using the bottles supplied. Results will be sent to BASMU.  Overseas please send to your local laboratory and indicate the results below. 
Blood Group		……………….
Hepatitis B		Negative                   Positive
Hepatitis C		Negative	         Positive
VDRL			Negative                   Positive
HIV			Negative	         Positive

If the examining Doctor believes further tests are necessary, please indicate and attach details.

7. Tuberculosis Screening
Patient has visible BCG scar	YES / NO

Comments on tuberculosis risk ( see patients BASMU 3 questionnaire)

8. Summary

Please summarise any relevant findings:

Examining  Doctors Name & Address		                   Practise Stamp.

Contact Telephone Number
FAX Number
Practice e-mail address
	
Doctor’s Signature…………………………………….

Patient Signature……………………………………..

Date of examination…………………………