Date received @BASMU

BASMU4				        Medical in Confidence
Aug24		          
British Antarctic Survey
Polar Service Medical Examination Record

Personal Details
Surname:
	First names:	
Date of birth:
	Job title:
	
NHS Number:
	Date of Examination:	

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.

1. General
Please discuss the BASMU 3 Questionnaire with the candidate, and summarise any significant Past Medical History.   Please note specifically any adverse effects / allergic reactions to either medication or food and any general anaesthesia/ surgery complications. If recent treatment or investigation, then please provide functional impact / recovery / follow ups.  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	
Please provide details                

	

Smoking	
Have you ever smoked?	Yes	No	
If so, how many do/did you smoke per day?
		
How many years have/did you smoked for?
		
Are you trying to quit smoking?	Yes	No	
Are you using nicotine replacement?	Yes	No	
Do you vape?	Yes	No	
Comment:	

Alcohol Consumption	
Do you drink alcohol?	Yes	No	
How many units do you drink in a week? 		
Standard glass of wine 175ml (12%) = 2.1units
Large glass of wine 250ml (12%) = 3units
Bottle of wine 750ml (12%) = 9 units
Can of beer/lager 440ml (5.5%) = 2 units
Pint of beer/lager 3.6% = 2 units
Pint of strong beer/lager 5.2% = 3 units
Spirits single 40% = 1 unitS                   	

2. Vital Statistics	
Height in cms	Weight in kgs	BMI
                                                   	
Waist circumference in cms	Hip circumference in cms

If BMI is greater than 35 then the person will be presently UNFIT for Antarctic Service. Please inform the person to contact BASMU at the earliest opportunity. 

3. Vital signs		
Pulse rate bpm
		
Pulse rhythm
		
Blood pressure
		
Respiratory rate
		
4. Vision	
Visual conditions / restrictions   
                       	Normal	Abnormal	
Comment:
	
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	
	Y/N	Details	
General Appearance			
Head and Neck			
Eyes			
Ears			
Nose			
Mouth and Pharynx			
Thyroid			
Lymph Nodes			
Chest and Lungs			
Breasts, if indicated			
Self - checks		Y	N	
Heart sounds			
Murmurs			
Abdomen			
Organomegaly			
Hernial Orifices			
Rectal Examination (if indicated)			
Prostate (males >45) own GP check within last 5 years acceptable			
Genitalia, if indicated. 			
Self-checks		Y	N	
Spine			
Lower limbs			
Peripheral pulses			
Varicose veins			
Upper Limbs			
Raynaud’s			
Skin			
Previous Cold Injury			
Scars			
Tattoos (brief descript. & area of body)			
Identifying Marks			
Neurological status			
Mental Health status			
Mood			
Affect			
Gynaecological examination, if indicated			

Please describe any other abnormal findings on examination

6. Investigations	
Urine analysis results:

12 lead ECG required for patients over the age of 50 at every BASMU Medical (annually) or if clinically indicated.  Attach 12 lead ECG please

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

7. Tuberculosis screening 
		
Patient has visible BCG scar	Yes	No	
Comment on TB risk (see patient’s BASMU 3 questionnaire)

8. Summary

Please summarise any relevant findings:

Examining Doctors Name & Address		                   Practise Stamp

Contact Telephone Number:
Practice Email address:

Doctor’s Signature…………………………………. Date of examination…………………………

Patient Signature……………………………………