____(A) Medical Examination - AWI

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____(A) Medical Examination - AWI

(A) Medical Examination

- POLARSTERN – cruises -

Version 2002-1

ALFRED-WEGENER-INSTITUTE FOR POLAR AND MARINE RESEARCH

Federal Republic of Germany

(page 1 - 4 to be filled in by examinee prior to medical examination)

Name (family, first): .............................................................................................................

Date of birth: .......................................................................................................................

Address (home): .......................................................................................................................

....................................................................................................................…

Phone no.home: ...................................... phone no.office: ...............................................

E-mail: ....................................……………… fax: ...............................................

Name of expedition: .......................................................................................................................

Kind of activity: .......................................................................................................................

Are you suffering from chronic diseases ?

If yes, what ?

(please underline the correct answer)

yes / no

Have you sufferd from acute diseases during the last twelve months resp.

After the medical examination before your last expedition ?

If yes, what ?

yes / no

Do you suffer from allergies ?

If yes, against:

yes / no

Have you suffered from frostbites ?

Do you take medicaments regulary?

If yes, which one and which dosis?

yes / no

yes / no

Do you smoke?

If yes, more than 10 cigarettes / day ?

yes / no

yes / no

Date of last tetanus vaccination:

.…...........…

Date of last diphtheria vaccination:

…................

Date of last polio vaccination: ....................

If vaccinations against tetanus, diphtheria and polio were performed more than 10 years ago,

revaccinations are required!

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Version 2002-1

Case history (Anamnesis)

What kind of diseases have you already had?

(If „yes“, please go into details)

Infectious diseases

infectious jaundice

tuberculosis

rheumatic fever

other diseases

(please underline the correct answerr)

yes / no

yes / no

yes / no

yes / no

Otorhinolaryngological diseases

nasal/paranasal sinus inflammations

tonsillar inflammation

dental diseases

other diseases

yes / no

yes / no

yes / no

yes / no

Ophthalmological diseases

glaucoma

cataract

vision disorders

yes / no

yes / no

yes / no

Lung diseases

pneumonia

costal pleurisy

asthma

other diseases

yes / no

yes / no

yes / no

yes / no

Cardiac and circulation diseases

high blood pressure

angina pectoris

myocardial infarction

blood supply disorders of legs

thrombosis

other diseases

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

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Abdominal diseases

(please underline the correct answer)

gallstones operated? yes / no

jaundice

other hepatic diseases

pancreatic diseases

gastric diseases

intestinal haemorrhage

intestinal polyps

other diseases

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

Kidney diseases and diseases of the lower abdomen

renal pelvis inflammation

urinary bladder inflammation

vesical calculus

renal calculus

prostate gland diseases

gynaecological diseases

other diseases

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

Metabolic disorders

diabetes mellitus

lipopathy

gout

thyroid gland diseases

other diseases

yes / no

yes / no

yes / no

yes / no

yes / no

Joint and spine diseases

rheumatism

joint inflammations

lumbago or ischialgia

intervertebral disc diseases

other diseases

yes / no

yes / no

yes / no

yes / no

yes / no

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Other diseases

skin diseases

blood diseases

malignant organ diseases

neurologic diseases or mood disorder

epileptic attacks

drug addiction

Did you take medicaments regulary?

If yes, which one, which dosis and how long?

(please underline the correct answer)

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

Have you been in hospital for treatment in the last two years?

If yes, when and wherefore?

Did You have a chest x-ray:

If yes, when, wherefore and with which result

X-ray other organs

If yes, when, wherefore and with which result

Did you have a head injury or other traumatic injury?

If yes, when and which kind?

yes / no

yes / no

yes / no

yes / no

Do you drink alcohol regulary?

dayly?

weekly?

If yes, what and how much?

yes / no

yes / no

Do you usually sport?

If yes, what kind and how often?

yes / no

Place, date: ..................................................................................................................................

Signature: ..................................................................................................................................

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Version 2002-1

Result of Medical Examination

(to be filled in by physician personally)

Name of examine: ..................................................................................................................

Date of examination: ................. Date of birth: ................ Height: ............... Weight: ............

Do you already know the person to be examined as a patient?

Do you regard the ears as healthy?

If not, what condition is stated?

Are the cervical lymph nodes enlarged?

(please underline the correct answer)

yes / no

yes / no

yes / no

Do you regard the eyes as healthy and the pupillary reflex as normal?

If not, which pathological change is stated?

Is the nasalbreathing free?

Are there any pathological findings at the teeth, tongue, tonsils and throat?

If yes, which condition is stated?

Do you regard skin and mucous as healthy?

If not, what condition is stated?

Do you regard the respiratory organs as healthy (percussory and auscultatory) ?

If not, which condition is stated?

Are the heart sounds rhythmical, clear and normally accentuated?

If not, what are your findings?

Are there any signs of cardial insufficiency?

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

yes / no

Blood pressure and heart rate at rest:

RR: ......... /........... HR: .......... /min

Do you regard skeleton and locomotor apparatus as healthy?

If not, what condition is stated?

Do you regard the nervous system as healthy? (Esp. Patellar reflex, plantar reflex,

abdominal reflex, Babinski and Romberg responses)?

If not, what condition is stated?

Digestive organs: Are the results of inspection, palpation and percussion of the

abdomen to be regarded as normal?

If not, what are your findings?

Do you regard the kidneys and urinary organs as healthy?

If not, what are your findings?

Are the pulses on the back of the foot easily palpable on both sides?

yes / no

yes / no

yes / no

yes / no

yes / no

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Version 2002-1

Resting and exercise ECG

Name:

Date of examination:

Resting ECG (Important: Please add the prints):

Interpretation:

Evaluation of the resting ECG:

Exercise ECG as per WHO standard (Important: Please add the documentation / prints):

For persons younger than 30 years, an exercise ECG is not obligatory in case of non- pathological

findings of the resting ECG and normal results of cardiological examination, no relevant physical

symptoms and no risk factors.

In connection with a new medical examination before an expedition a repetition of the exercise ECG is

compulsary for persons younger than 40 years after two years and for persons older than 40 years

after one year, if the cardiological examination and resting ECG shows no pathological findings.

Heartrate at max. exertio: 200 minus age

Excerpt from the ergometric protocol

(if no separate protocol is added as enclosure):

Before exertion: blood pressure: heart rate:

Initial exertion with ............. watt blood pressure: heart rate:

At exertion with 150 watt: blood pressure: heart rate:

At maximum exert. with ......….watt blood pressure: heart rate:

1 minutes after exertion: blood pressure: heart rate:

3 minutes after exertion: blood pressure: heart rate:

5 minutes after exertion: blood pressure: heart rate:

Stop because of:

Symptoms:

Extrasystoles?

Arrhythmia?

Pathological changes during terminal stage:

(please underline the correct answer)

yes / no

yes / no

yes / no

yes / no

Evaluation of exercise ECG:

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Name:

Date of examination:

Laboratory diagnostics

Blood sedimentation rate (BSR):

Blood count:

Leukocytes:

Erythrocytes:

Hemoglobin:

Hematocrit :

MCV:

MCH:

Blood glucose:

Creatinine:

Uric acid:

Glutamic-pyruvic transaminase:

Gamma-glutamyltransferase:

Cholesterol:

HDL cholesterol:

LDL cholesterol:

Urinanalysis:

Blood group:

Spirometrie (please add documentation):

Final medical appraisal of the participant`s fitness:

Place, date: .............................................................................................................................................

Signature: ................................................................................................................................................

Stamp and telephone: ...........................................................................................................................

Enclosures:

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