Primary physician’s report form CR 07

(For use by an on-shore physician caring for a sick or injured seafarer)

to be filled in 2 copies - 1 for vessel, 1 for physician

Administrative information
Patient
Surname_______________________ First name_______________________
Sex_____________ Date of birth (dd-mm-yyyy)__________________________
Nationality________________________________________________________
Occupation________________________________________________________
Seafarer registration number__________________________________________
Employer
Name_____________________________________________________________
Telephone No.__________________________ Fax No._____________________
E-mail address______________________________________________________

Medical information
Key dates
■ Date of injury or of onset of illness (dd-mm-yyyy)_____________________________________________________________
■ Dates of previous medical consultations (dd-mm-yyyy)_________________________________________________________
■ Date of current consultation (dd-mm-yyyy)___________________________________________________________________
History
■ Symptoms or (in the case of injury) circumstances _____________________________________________________________
_______________________________________________________________________________________________________
■ Personal history pertinent to current illness ___________________________________________________________________
_______________________________________________________________________________________________________
■ Clinical examination ____________________________________________________________________________________
_______________________________________________________________________________________________________
■ Findings of diagnostic tests (X-ray, CT or MRI scans, lab. tests, etc.)______________________________________________
______________________________________________________________________________________________________
■ Diagnoses
● 1__________________________________________________________________________________________________
● 2__________________________________________________________________________________________________
● 3__________________________________________________________________________________________________
Summary notes of contact with telemedical service_____________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
■ Treatment prescribed____________________________________________________________________________________
■ Reasons for stopping treatment ____________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
■ Suggested follow-up action (examinations, tests, treatment, etc.)__________________________________________________
■ Fitness to work and restrictions on shipboard activities__________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Physician’s professional identity

Name___________________________________________________________
Issued by________________________________________________________
Date issued_______________________________________________________
Speciality________________________________________________________
Telephone No.__________________ Fax No.____________________________
E-mail address_____________________________________________________
Office address_________________________________________________________________________________________
Signature___________________________________