Msc Medical Summary Form – Fill Out and Use This PDF

COMMANDER

MILITARY SEALIFT FLEET SUPPORT COMMAND

Medical Department (CODE: NO2M)

1283 Tow Way Drive

Norfolk, VA 23511-2419

VOICE: 1-866-827-4955	FAX: 1-866-324-4955
(757) 443-5760	(757) 443- 5767

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Mariner Name / last 4 SSN

Current Assignment

MEDICAL SUMMARY FORM

(ALTERNATIVELY, A WRITTEN REPORT THAT ADDRESSES BELOW ELEMENTS MAY BE ATTACHED)

Note to examining provider: Please take note that the Seafaring environment is arduous and exposes personnel to many hazards. The health status of crew members is important to reduce the incidence of illness or injury when remote from shore side medical facilities. It is essential that crew members be physically fit to perform their duties to include responding to and operating ship’s emergency equipment. Crew members must be able to wear Self Contained Breathing Apparatus, handle fire equipment, damage control equipment, climb ladders and stairs, enter small spaces, and carry objects up to 50 lbs from the pier to the ship. The fitness of the crewmember is important to the safe operation of the ship and affects the entire well being of the ship.

MEDICAL SPECIALTY RECOMMENDED:

MEDICAL PROBLEMS TO BE ADDRESSED:

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SIGNIFICANT HISTORY AND PHYSICAL FINDINGS: (For elevated Blood Pressure evaluation, include serial BP readings indicating proper control.)

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SIGNIFICANT LAB RESULTS, X-RAY, EKG, ETC. PLEASE ATTACH APPROPRIATE RESULTS SHEET:

(For elevated Glucose evaluation, include repeat Fasting Blood Sugar results: For individuals diagnosed with Diabetes Mellitus, include

Fasting Blood Sugar and Hemoglobin A1c result: For Liver Disease work-up, include liver function tests as well as panels for Hepatitis A, B&C)

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DIAGNOSIS/ DIAGNOSES:

CONTINUE ON REVERSE OF FORM

Page 2: Patient’s name/ssn:__________________________________

TREATMENT RECEIVED (List all medications, physical therapy, etc.)

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PROGNOSIS / LIMITATIONS / RECOMMENDATIONS FOR FOLLOW UP. Please note that this Mariner is subject to long (4-6 months) continuous sea voyages, rough seas, extreme heat/cold conditions, unstable work platforms and strenuous work environments. He/she may be far from definitive medical care for prolonged periods.

Periods of follow-up suitable for sailing with MSC should not be more frequent than every 5-6 months.

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AUTHORITY TO RELEASE PRIVILEGED MEDICAL INFORMATION: I hereby authorized release to the Medical Officer, Military Sealift Fleet Support Command, privileged medical correspondence and records in my case.

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Mariner’s signature	Date

Your current phone number where you can be reached: ______________________________________

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Physician’s Name	Physician’s Signature
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Please indicate your specialty and accreditation	Date signed by Physician

ADDRESS:TELEPHONE

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Medical Summary Form ( (Revised 1/18/07)