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DATE OF EXAMINATION
First
Middle
SOCIAL SECURITY #
AGE
/
HOME ADDRESS PHONE
CITY
STATE
ZIP
HEALTH HISTORY
YES NO YES NO YES NO
Asthma Kidney Tuberculosis Diabetes Nervous Stomach Rheumatic Fever Over the counter drug use
IF ANSWER TO ANY OF THE ABOVE IS YES, EXPLAIN:
Muscular Disease Psychiatric Disorder Cardiovascular Disease Gastrointestinal Ulcer Ethanol use Rx drug use
Head or spinal injuries Seizures, fits, convulsions or fainting Extensive confinement by illness or injury Any other nervous disorder Suffering from any other disorder Permanent defect from illness, disease or injury
Good Left/20
Fair Both/20
Evidence of disease or injury: Right Color Test: Horizontal Field of Vision: HEARING: Right Ear Evidence of disease or injury: Right AUDIOMETRIC TEST: Decibel loss at 500 HZ 1,000 Hz 5,000 Hz THROAT: THORAX: Heart: If organic disease is present, is it fully compensated? Blood Pressure: Pulse: Lungs: ABDOMEN: Scars Abdominal Masses Systolic Before Exercise 2,000 Hz 6,000 Hz Right Left ear
Left
Tenderness
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National Commission for the Certification of Crane Operators 2007 MC CH REV 05/07
HERNIA:
Yes
No
Is truss worn? No
GASTROINTESTINAL: Ulceration or other disease? GENITO-URINARY: REFLEXES: Scars: Rhomberg Pupillary: Accommodation: KNEE JERKS: Right Left REMARKS: Normal Normal Increased Increased Light
R R
L L Absent Absent
Lower Alb.
Spine Sugar
GENERAL COMMENTS:
SIGNATURE
CITY
STATE
ZIP
MEDICAL EXAMINERS CERTIFICATE TO BE COMPLETED ONLY IF OPERATOR IS FOUND QUALIFIED MEDICAL EXAMINERS CERTIFICATE
I certify that I have examined
CRANE OPERATORS NAME (PRINT)
with the knowledge of his/her duties, I nd him/her qualied under the regulations. Qualied only when wearing corrective lenses. Qualied only when wearing a hearing aid. Qualied see Accommodation Statement attached. A complete examination form for this person is on le in my ofce:
ADDRESS
with the knowledge of his/her duties, I nd him/her qualied under the regulations. Qualied only when wearing corrective lenses. Qualied only when wearing a hearing aid. Qualied see Accommodation Statement attached. A complete examination form for this person is on le in my ofce:
ADDRESS
DATE OF EXAMINATION
DATE OF EXAMINATION
SIGNATURE OF OPERATOR
SIGNATURE OF OPERATOR
ADDRESS OF OPERATOR
ADDRESS OF OPERATOR
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National Commission for the Certification of Crane Operators 2007 MC CH REV 05/07