3287

Welcome to All Sea Medical

"Instructions for Your Physical Examination"

Below are instructions regarding your physical examination and how you can submit your medical
documents for processing of your Seafarer Medical Fitness Certificate (SMFC formerly known as
PEME). Food workers and Engine workers must additionally complete the “Food Workers and Deck
& Engine Workers Testing” instructions. You must fill in ALL portions of the documents received as
well as complete all required tests. After your tests are fully completed and signed please submit in
one scanned file (.pdf format if possible) to documents@allseamedical.com. It is possible that after
you submit your files you will be asked to repeat tests, perform new tests, or see a medical specialist
for further opinions. If you are not using your own doctor, our affiliate clinic will send us your
paperwork after your examination. PLEASE MAKE SURE THAT THE PHYSICIAN HAS SIGNED THE
APPLICATION! This would be one of the items can can delay your review, especially if you cannot
return to the clinic.
Step 1- Go to www.allseamedical.com there are two ways to get your physical examination, the
first is "Using your own doctor", you can click on this tab and follow the prompts to payment.
Secondly, is choosing one of our affiliate clinics; you should choose the clinic you want to go to and
follow the prompts to payment. If you do not see your clinic on the list, choose the city you would
like to go for your physical examination and we will find you an available clinic. If using a credit card
that is not yours, please send an email to us and tell us the name on the card you used to make your
payment. This will trigger our system to send you the proper Carnival medical documents. Please
allow 48 hours for paperwork to arrive. To clarify your payment will ONLY include your physical
examination. Dental examinations or special testing will be paid by you separately.

Step 2- Schedule your appointment at least 4 weeks prior to your start date. If using your own
doctor, let them know the tests involved (see below as to the needed examinations) so they can be
prepared. If you are unable to schedule an appointment within 4 weeks, let the head of the
department or schedulers know.

Step 3- Take all the documents that you receive from us and fill them out at your doctor’s office with
your doctor. Make sure you answer completely so there are no delays. Also make sure your doctor
fills in all the details to your “Yes” answers (part 5). If documents are not fully completed you may
have to return to your doctor or the clinic!! Before leaving the doctor's office or clinic, please request
a copy of the paperwork, this way you can send it to us at documents@allseamedical.com. You will
also need this paperwork to take on board with you.

Please remember ONLY your original "Seafarer Medical Certificate" can be

used to work on the Ship. The medical exam documents CAN be copies. Crew
Member must allow up to 14 working days with regular mail or shorter if you
should choose to pay special delivery.
 3287

ALL SEA MEDICAL CHECKLIST

Please check off the requirements below as they are completed.
Once all the requirements are checked off, please submit ALL the items together in
ONE EMAIL as a PDF file to Documents@allseamedical.com

 Application/Physical exam form completed. NP or PA can perform the exam

but, the documents MUST be signed by your Doctor. Printed name and NPI/ LICENSE
number must be included (MD or DO ONLY)
 EKG
 Chest X Ray
 Lab results
 MMR Proof *2 Doses are required with proof of both doses, or positive IgG titers showing
immunity to Measles, Mumps and Rubella
 Dental exam form signed by your Dentist Dental Examination must be free and
clear of any cavities, abscesses or disease. If dental work is not completed, the review will
not be complete.
 Passport (scanned copy of the first page must be submitted)

Blood Test requirements:

**Please make sure your health care professional has requested the following blood and urine
test:
EVERYONE MUST DO THE FOLLOWING: FOOD WORKERS ONLY:
 COMPLETE BLOOD COUNT
 CREATNINE HEPATITIS A VACCINE * 2 DOSES
 AST (new hires only require the first does to
 ALT process your medicals)
 BUN
 FIRST DOSE
 Total BILIRUBIN
 SECOND DOSE
 HIV
 HEP B SURFACE ANTIGEN OR
 TOTAL FASTING CHOLESTEROL  HEPATITS A TITERS (with positive
 FASTING GLUCOSE antibodies) (IgG & IgM)
 URINARY ANALYSIS
DECK & ENGINE WORKERS ONLY:
 AUDIOGRAM
 COLOR VISION
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SPECIAL NOTES: Dental Examination must be free and clear of any cavities, abcesses or
disease. If dental work is not completed, the review will not be complete. Also,
Cholesterol testing if needed must be completed as well.
 3287

Instructions for Food Workers

and Deck and Engine

Food Workers and Deck & Engine Workers Additional Tests- The following tests
are in addition to the tests listed in the "General Instructions" page for food
workers and Deck & Engine only! Attach results of these tests with your other
paperwork and send to documents@allseamedical.com Please do not perform if
you are not one of the above. If you are unsure if you require these tests please
contact your department.

FOOD WORKERS ONLY

1- Hepatitis A Vaccine ( New hires only require the first dose to process your medical).

☐ First Dose Or ☐ Hepatitis A Titers (IgG & IgM)

☐ Second Dose

DECK & ENGINE WORKERS ONLY

☐ Audiogram ☐ Color Vision

This document and its attachments may contain privileged and confidential information and/or protected health information (PHI) intended
solely for the use of All Sea Medical and the recipient(s) named above. If you are not the recipient, or the employee or agent responsible for
delivering this message to the intended recipient, you are hereby notified that any review, dissemination, distribution, printing or copying of
this email message and/or any attachments is strictly prohibited. If you have received this transmission in error, please notify the sender and
permanently delete this email and any attachments.

Page 3 of 3 General Instructions - rev.6 6/2018

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Carnival Cruise Line

3655 Northwest 87th Avenue
Miami, Florida 33178

Authorization to Obtain and Release Medical Information

Olga Katherine Barragan Samaniego
Name _________________________________________________ 03/05/1993
Date of Birth_______________
Address __________________________________________________________________________

This Authorization applies to the Individual named above. This form can only be signed by the named Individual.

I AUTHORIZE:

a. Carnival Cruise Line, a division of Carnival Corporation (Company) to obtain and share medical reports from any medical
professional, medical care provider, hospital, clinic, laboratory, pharmacy or pharmacy benefit manager, electronic health
record provider, insurance company, or any other similar person or organization with health information about me. Health
information includes: (i) my entire medical record and medical history, prescription history, and other health information
(ii) confidential information related to Human Immunodeficiency Virus (HIV) or Aids, other communicable diseases and
mental illness (including psychotherapy notes) and (iii) genetic information and genetic test results, to the extent permitted
by law.

b. The Company to share medical information with other cruise brands within Carnival Corporation, their affiliated companies,
agents, medical providers, insurers, reinsurers, or any person or entity entitled to receive such information by law or as I
may further consent. Information collected under this authorization may be used to evaluate my Pre-Employment Medical
Examination forms; administer medical benefits; evaluate any claim for medical benefits; for reinsurance or other insurance
purposes; and/or or to conduct other legally permissible activities. I further understand that if I refuse to sign this
authorization, the Company may not be able to process my PEME/SMFE, administer medical benefits coverage or evaluate
claims for medical benefits.

This authorization is valid from the date shown below through the entirety of my employment with the Company. A photocopy of
this authorization will be as valid as the original. I am entitled to a copy of this authorization.

Signed at City State Country Date (Month) (Day) (Year)

Olga Katherine Barragan Samaniego

Signature (Printed name)
 ALL SEA MEDICAL
EMAIL/TEXT/FAX CONSENT FORM
PURPOSE: This form is used to obtain your consent to communicate with you by email/text or fax
regarding your Protected Health Information. ALL SEA MEDICAL LLC, (ASM), offers patient/crew
members the opportunity to communicate by email/text or fax. Transmitting patient/crew members
information by email/text or fax has a number of risks that patients/crew members should consider before
granting consent to use them for these purposes. ASM, will use reasonable means to protect the security
and confidentiality of the information sent and received. However, ASM cannot guarantee the security
and confidentiality of email/text or fax communication and will not be liable for inadvertent disclosure of
confidential information.

I AUTHORIZE, All Sea Medical, LLC. (Company) to obtain and share medical reports from any medical
professional, medical care provider, hospital, clinic, laboratory, pharmacy or pharmacy benefit manager,
electronic health record provider, insurance company, or any other similar person or organization with health
information about me. Health information includes: (i) my entire medical record and medical history,
prescription history, and other health information (ii) confidential information related to Human
Immunodeficiency Virus (HIV) or Aids, other communicable diseases and mental illness (including psychotherapy
notes) and (iii) genetic information and genetic test results, to the extent permitted by law.

I AUTHORIZE, The Company to share medical information with any of our affiliated companies, agents, medical
providers, insurers, reinsurers, or any person or entity entitled to receive such information by law or as I may
further consent. Information collected under this authorization may be used to evaluate my Pre-Employment
Medical Examination forms; administer medical benefits; evaluate any claim for medical benefits; for reinsurance
or other insurance purposes; and/or or to conduct other legally permissible activities. I further understand that if
I refuse to sign this authorization, the Company may not be able to process my PEME/SMFE, administer medical
benefits coverage or evaluate claims for medical benefits.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

This authorization is valid from the date shown below through the entirety of my employment with the Company.
A photocopy of this authorization will be as valid as the original. I am entitled to a copy of this authorization.

My Consented Email Address is: ___________________________________________________

My Consented Phone number is: ____________________________________________________

My Consented Fax number is: _____________________________________________________

Signed at City State Country Date (Month) (Day) (Year)

Signature (Printed name)

ASM Patient Email/Text/Fax Consent Form – 2018 – 05 v.2

 3287

Seafarers Medical Fitness Examination Form - Part 1

IMPORTANT: All pages must be entirely completed. Entire document is to be completed by proposed
employee and verbally reviewed/signed by licensed medical practitioner ( M.D. or D.O. ONLY). Blank sections
of form signed by medical practitioner other than a medical doctor ( e.g. NP or PA) will invalidate this
document. Any omissions or misrepresentations of any of the following documents may lead to termination,
denial of employment or loss of health benefits.

Personal
☐ Information of Examinee
Olga Katherine
First Name:___________________________ Barragan Samaniego
Last Name:_______________________________ Middle:________________

Date of Birth (MM/DD/YYYY):_____/_____/________

03/05/1993 (099) 558-5504
Nationality:______________________ Telephone:______________

katyta_bs93@hotmail.com
Email:__________________________________ Crew ID Number (if not available provide passport number)______________________________

Assistant Waitress
Position:__________________________ Food and Beverage Services
Department:__________________________ Date of Hire:___/____/_______
Crew Member Status (please check one):  Returning  Rehire  New Hire
Have you ever been on “Rehire” or “Retirement “ Status:  Yes  No

1. Personal Physician
Do you have a personal physician, doctor or healthcare provider?  Yes  No
Have you seen any physician, doctor or healthcare provider in the last 10 years?  Yes  No
If “Yes” to either of the above questions please complete the following: IMOBNK

Doctor’s Name__________________________________________ Telephone_________________________

/
Address (City/Country Only)________________________________ Date last seen _____________________
Reason for last visit_________________________________________________________________________
_________________________________________________________________________________________

2. Medications
Do you currently take any prescribed medications, over the counter medications or vitamins?  Yes No
Have you taken any prescribed medications in the last 5 years?  Yes No
If “Yes” to either of the above questions please complete the following (if more space needed use Page 5):

Medication Name Date Started/Stopped Reason for medication

1 _________________ __________________ ______________________________________________________

2 _________________ __________________ ______________________________________________________

3 _________________ __________________ ______________________________________________________

4 _________________ __________________ ______________________________________________________

I certify the answers above are true and complete to the best of my knowledge. I
Doctor’s Name understand that any omissions or misrepresentations is grounds for termination
x and may constitute denial of health benefits in the event I become ill or injured.
Doctor’s Signature Date(MM/DD/YYYY) Olga Katherine Barragan Samaniego
Examinee Name________________________________________
x
Stamp/Seal Here
Examinee Signature Date (MM/DD/YYYY)
2018-06_ v 5
All Sea Medical LLC
 3287

Seafarers Medical Fitness Examination - Part 2

Each section must be individually asked and completed by examinee and reviewed by medical doctor. If
answer is “Yes” to any of the following questions please complete details on PART 5.

3. Personal Health History

A. Do you smoke  Yes  No If ‘Yes” # cigarettes per day___________
B. Do you drink  Yes  No If “Yes” # drinks per day_________ ____
C. Do you have any allergies Yes  No If “Yes” to what_______________________________________________

Have you ever been told you had, been diagnosed with, or treated for any of the following:
4. General Health
A. High blood pressure?  Yes  No If “Yes” Most recent reading__________Date when diagnosed:___________
B. High Cholesterol?  Yes  No If “Yes” Most recent level____________ Date when diagnosed: __________
C. Diabetes?  Yes  No If “Yes” Most recent HgA1C__________ Date when diagnosed:__________
D. Are you on Insulin  Yes  No

5. ENT
A. Eye Glasses/ Contacts  Yes  No E. Chronic Otitis Media  Yes  No
B. Color Blindness  Yes  No F. Hearing Loss/ Use of Hearing Aid  Yes  No
C. Pinguecula/ Pterygium  Yes  No G. Rhinitis/ Nasal Septum Defect  Yes  No
D. Other Eye Disorders  Yes  No H. Tonsillitis/ Vocal Cord Problems  Yes  No

6. Lung and Respiratory 7. Males Only

A. Asthma  Yes  No A. Any difficulty voiding urine  Yes  No
B. Emphysema/COPD Yes  No B. Any history of Nocturia  Yes  No
C. Chronic Bronchitis  Yes  No C. Prostate problems  Yes  No
IMOBK

D. Sleep Apnea/ Use of CPAP  Yes  No Date and level of last PSA ______________
E. Tuberculosis  Yes  No Date of last prostate exam______________
F. Trouble breathing, Chronic Cough or any other disease or E. History of testicular lumps  Yes  No
disorder of the lungs or respiratory system  Yes  No

8. Heart and Blood Vessels

A. Chest Pain/Tightness/Discomfort  Yes  No G. Heart Failure Yes  No
B. Angina  Yes  No H. Blood Clot or DVT Yes  No
C. Coronary Artery Disease  Yes  No I. Stroke Yes  No
D. Heart Attack  Yes  No J. Transient Ischemic Attack (TIA) Yes  No
E. Heart Murmur/Valve Disorder  Yes  No K. Aneurysm Yes  No
F. Irregular Heartbeat/Palpitations  Yes  No L. Varicose Veins Yes  No
L. Any other disease or disorder of the heart, blood vessels or circulation Yes No

I certify the answers above are true and complete to the best of my knowledge. I
Doctor’s Name understand that any omissions or misrepresentations is grounds for termination
x and may constitute denial of health benefits in the event I become ill or injured.
Doctor’s Signature Date(MM/DD/YYYY) Olga Katherine Barragan Samaniego
Examinee Name________________________________________
x
Stamp/Seal Here
Examinee Signature Date (MM/DD/YYYY)

2018-06_ v 5 All Sea Medical LLC

 3287

Seafarers Medical Fitness Examination - Part 3

Have you been told you have or ever had any of the following (provide details for all “Yes” responses on part 5):
9. Genitourinary
A. Sugar, Blood or Protein in Urine  Yes  No D. Kidney Stone  Yes  No
B. Chronic Kidney Disease  Yes  No E. Urinary Tract Infection  Yes  No
C. Acute Kidney Injury/Failure  Yes  No
D. Any other disease or disorder of the Urinary Tract, Kidney, Bladder  Yes  No

10. Brain and Nervous system

A. Dizziness or Vertigo  Yes  No F. Neuropathy  Yes  No
B. Seizure or Epilepsy  Yes  No G. Memory Loss or Impairment  Yes  No
C. Loss of Consciousness/ Fainting  Yes  No H. Headaches (including Migraines)  Yes  No
D. Weakness or Paralysis  Yes  No I. Tremors  Yes  No
E. Any other disease or disorder of the Brain, Spinal Cord or Nervous System  Yes  No

11. Infectious Disease

A. HIV (Human Immunodeficiency Virus) Yes  No
B. Malaria/ Dengue Yes  No G. Genital Warts Yes  No
C. Hepatitis B or C or A Yes  No H. Gonorrhea Yes  No
D. Rheumatic Fever Yes  No I. Syphilis Yes  No
E. Genital Herpes Yes  No J. Chlamydia Yes  No
F. Any other acquired infection that required or requires treatment Yes  No

12. Gastrointestinal
A. Ulcer  Yes  No F. Hemorrhoids/Fissure  Yes  No
B. Heartburn/Acid Reflux (GERD)  Yes  No H. Irritable Bowel  Yes  No
C. Crohn’s Disease/ Ulcerative Colitis  Yes  No I. Pancreatitis  Yes  No
D. Blood in the stool IMOBK  Yes  No
E. Any other disease of the digestive and gastrointestinal system
including pancreas, gallbladder, liver, esophagus, stomach or intestines  Yes  No

13. Musculoskeletal/Autoimmune/ Skin

A. Arthritis Yes  No L. Scoliosis Yes  No
B. Gout Yes  No M. Sciatica Yes  No
C. Lupus Yes  No N. Atopic/ Contact Dermatitis Yes  No
D. Fibromyalgia Yes  No O. Psoriasis Yes  No
E. Carpal Tunnel Syndrome Yes  No P. Eczema Yes  No
F. Hernia (Inguinal/Abdominal) Yes  No Q. Amputation Yes  No
G. Chronic Fatigue Syndrome Yes  No R. Alopecia Yes  No

H. Chronic Pain ( including but not limited to Wrist, Shoulder, Knee, Upper and Lower Back Pain) Yes  No
I. Any other injury, fracture, disease, disorder, impairment, or previous surgery of the bones, joints
(including but not limited to knees, hips, back), nerves, extremities, spine, neck, or back Yes  No
J. Any other diseases or disorders of the skin or Tattoos Yes  No
K. Any other rheumatologic disorders Yes  No
I certify the answers above are true and complete to the best of my knowledge. I
Doctor’s Name understand that any omissions or misrepresentations is grounds for termination
X and may constitute denial of health benefits in the event I become ill or injured.
Doctor’s Signature Date(MM/DD/YYYY) Olga Katherine Barragan Samaniego
Examinee Name________________________________________
x
Stamp/Seal Here
Examinee Signature Date (MM/DD/YYYY)

2018-06_ v 5 All Sea Medical LLC

 3287

Seafarers Medical Fitness Examination - Part 4

Have you been told you have or ever had any of the following (provide details for all “Yes” responses on part 5):
15. Reproductive (Female Only)
A. Date of last Gynecology check up __________________
B. Are you currently pregnant Yes  No
Date of last menstrual period _____________________
C. Any disorders of Uterus (includes but not limited to fibroids
endometriosis, any irregular bleeding or menstruation) Yes  No
D. Any history of irregular periods Yes  No
If “Yes” when and explain ________________________
E. History of heavy bleeding/pain that
could limit your daily activities Yes  No
F. Do you take any form of contraception Yes  No
E. Any disorders of the breast? Yes  No
Date of last breast exam_______________
Date of last mammogram______________
F. Any disorders of the cervix Yes  No
Date of Last Pap Smear_______________
( If none state “NONE”. If previous Pap
Smear Please include results or mark on
Part 5- Additional Comments) IMOBK

If “Yes” which type _____________________________ G. Any disorders of the Ovaries Yes  No

16. Psychiatric and Mental Health

A. Anxiety/ Nervousness  Yes  No G. Claustrophobia  Yes  No
B. Depression  Yes  No H. Bipolar Disorder  Yes  No
C. Psychosis  Yes  No I. Obsessive Compulsive Disorder  Yes  No
D. Suicidal Thoughts/Attempts  Yes  No J. ADD/ ADHD  Yes  No
E. Adjustment Disorder  Yes  No K. Post-Traumatic Stress Disorder  Yes  No
F. Insomnia/ Sleeping Disorder  Yes  No L. Anorexia/ Bulimia  Yes  No
G. Any other Emotional, Psychiatric or Mental Health Disease or Disorder  Yes  No

17. General Health History

A. Have you ever been hospitalized  Yes  No
B. Have you ever had surgery Yes  No
C. Have you ever been signed off as sick (MSO) or medically disembarked from a ship Yes No
D. Have you ever been refused any job or military service for a health condition/illness or injury?  YesNo
E. Have you ever sought or received treatment/counseling for the use of alcohol or drugs? Yes No
F. Have you ever used marijuana, cocaine, heroin, methamphetamine or any illegal substances? Yes No
G. Have you ever used or been prescribed tranquilizers, sedatives, amphetamines,
narcotics or any other controlled substances? Yes  No
H. In the last 10 years have you requested or received payments, benefits or a
pension because of injury, accident, sickness, disability or impairing condition?  Yes No

18. Other than stated previously have you in the last 10 years:
A. Have you ever completed a separate PEME/Seafarer Exam (Pre-Employment Medical Examination) Yes No
If “yes” for above which facility completed the PEME? _________________________________________________
B. Have you ever been declared “Unfit for duty” Yes No
C. Have you consulted or seen a healthcare provider (doctor, psychiatrist, chiropractor, psychologist counselor,
physical therapist)other than for a PEME? Yes No
D. Have you been a patient in a hospital, clinic or rehab facility? Yes No
E. Had any diagnostic tests ( ECG, XRAY, blood tests, CT scan, MRI, heart scan, biopsies etc.)? Yes No
F. Been advised to have any test or surgery which has not been completed? Yes No
I certify the answers above are true and complete to the best of my knowledge. I
Doctor’s Name understand that any omissions or misrepresentations is grounds for termination
x and may constitute denial of health benefits in the event I become ill or injured.
Doctor’s Signature Date(MM/DD/YYYY) Olga Katherine Barragan Samaniego
Examinee Name________________________________________
x
Stamp/Seal Here Examinee Signature Date (MM/DD/YYYY)

2018-06_ v 5
All Sea Medical LLC
 3287

Seafarers Medical Fitness Examination - Part 5 (Additional Details)

Medical examiner to fill in details to all “Yes” responses and any additional details from
previous questions below. If no additional Sample Format:
details are necessary please check here  Question 13 C – Diagnosis (with signs, symptoms and severity). Dates
of diagnosis and all evaluations, Tests and Treatments. Time since
(Please write legibly): last symptom or Date of Recovery.Name, city and telephone of
treating healthcare provider. IMOBK

Question #/ Letter Details: Please see sample format above for guidance
(e.g. 2.D)

I certify the answers above are true and complete to the best of my knowledge. I
Doctor’s Name understand that any omissions or misrepresentations is grounds for termination
x and may constitute denial of health benefits in the event I become ill or injured.
Doctor’s Signature Date(MM/DD/YYYY) Olga Katherine Barragan Samaniego
Examinee Name________________________________________
x
Stamp/Seal Here
Examinee Signature Date (MM/DD/YYYY)

2018-06_ v 5
All Sea Medical LLC
 3287

Seafarers Medical Fitness Examination- Part 6 - Physical Examination

Following examination must be fully completed by qualified physician, MD or DO only. Any

misrepresentation or omissions of the below findings can lead to lead termination, loss of health
benefits or denial of employment. If additional comments needed please use Page 5. IMOBK

Examinee Name First: Olga Katherine Last: Barragan Samaniego Crew ID

Method of confirmation of identity: Passport Crew ID  Driver’s License  Other__________________________

Height: (ft) (in) (cm) Blood Pressure-measure 3 times at minimum 5 minute intervals

Weight: kg Systolic
Diastolic
BMI:
Heart Rate

Heart Is there any evidence of: Blood Vessels Hernias

Enlargement  Yes  No Any Varicosities  Yes  No Are any hernias present  Yes  No
Murmurs  Yes  No Bruits  Yes  No Location/ Size:______________________

General Appearance – please describe any abnormalities on General Appearance – please describe any abnormalities
Page 5 Normal Abnormal on Page 5
Page 5 Normal Abnormal

1. Head, Face, Neck, Scalp  

9. Nervous System  
2. Eyes ( Retinopathy, Retinal Changes)  
(Reflexes, Gait, Tremor etc.)
3. Ears, Nose, Throat  
10. Abdomen (including Scars)  
4. Skin, Lymph Nodes  
11. Anus No longer
 required

5. Breast Exam   (skin tags, warts, hemorrhoids)
(Masses, Gross Changes) No longer
12. External Genitalia  required

6. Thyroid   (including testicular,prostate)
7. Lungs, Pleura and Respiratory Tract   13. Spine (Signs of scoliosis,  
8. Kidneys, Genitourinary Tract   Upper/Mid/Lower Flexibility)
14. Musculoskeletal -wrist,shoulder etc,  
Glasses or Contact Lenses Yes  No If “Yes” please state type and purpose_________________________________
Color Vision  Not Tested  Normal  Doubtful  Defective Ishihara Test Performed  Yes  No
Visual Acuity Unaided Aided Visual Fields
Right Eye Left Eye Right Eye Left Eye Right Eye Left Eye
Distant Normal Normal
Near Abnormal Abnormal

Whisper Test-if abnormal please perform pure tone audiometry -Has the examinee ever been your patient?  Yes  No
Normal Abnormal -If “Yes” are details included in history given?  Yes  No
Right Ear   -Was the exam conducted in a language other than English
Left Ear   YesNo If “Yes” which language?____________

I certify that I have examined the above named Stamp/Seal Here

applicant to the medical standards provided by Doctor’s Name
Carnival Cruise Lines and can attest that this
applicant has completed all required tests with a full
x
physical examination. I have identified no reportable Doctor’s Signature Date (MM/DD/YYYY)
deficiencies other than those reported above.

All Sea Medical LLC

 3287

Seafarers Medical Fitness Examination- Part 7 - Physical Examination Cont’d

Please follow instructions for each section to avoid denial of employment,benefits,boarding or repeat testing.
Examinee Name First: Olga Katherine Last: Barragan Samaniego Crew ID:
Basic Dental Exam To be completed by Dentist Body Chart Details:
Please clearly mark affected teeth on
dental chart below using the following
symbols directly on he
t affected tooth:
Decay/Carry - ≠
Dental Filling - F
Broken/Fracture Tooth - Ɵ
Tooth Missing/Extracted - X
rm
fo
m
xa
le
ta
en
ad
on
ed
et
pl
m
co
be
To

Labs and Additional Tests – If any clinically significant abnormalities please repeat Specific Tests:
test or perform confirmatory test. Attach ALL labs on final document submission. EKG -  Normal  Abnormal
Normal Abnormal Normal Abnormal
Lipid Panel ( BMI 30+ /Men Age 35+
CBC   Hepatitis B Screen  
Women 45+)
BUN   No longer
Hepatitis required 
C Screen 
 Normal  Abnormal
Creatinine   No longer
VDRL/RPR required  
SGOT/AST and SGPT/ALT   HIV Screen  
Bilirubin   Chest X-Ray  
No longer
Alkaline required
Phosphatase   No longer
Drug Test required 
No longerTest
Pregnancy required  

Food workers ONLY (Food, beverage, Vaccination- ***Mandatory to attach proof of immunity (titer levels) or
and anyone who manipulates ice or proof of Vaccination (Certificate) for MMR, Varicella and Hepatitis A.
food): Please note that it is now mandatory for Food workers A. Measles Mumps and Rubella (MMR):
to have vaccination for Hepatitis A or proof of immunity. First dose: Yes No Second dose: Yes No
Blood titer: Yes No
A. Hepatitis A Vaccine: First dose: Yes 
B. No longer required
 (chickenpox):
Varicella 
Second dose: Yes No Blood titer: Yes No First  Yes
dose:
No longer No
required Second dose: Yes No
Blood titer: Yes No
_______________________________________
I certify that I have examined the above named Stamp/Seal Here:
applicant to the medical standards provided by Doctor’s Name
Carnival Cruise Lines and can attest that this applicant
has completed all required tests with a full physical
x
examination. I have identified no reportable Doctor’s Signature Date (MM/DD/YYYY)
deficiencies other than those reported above.
Stamp/Seal Here

All Sea Medical LLC

 3287

All Sea Medical Dental Examination Form

Olga Katherine Barragan Samaniego

Note: All Dental work must be completed before you will be eligible for a Fit for Duty Seafarer's Certificate.

Examinee Name First: Last: Crew ID:

Basic Dental Exam
Please clearly mark affected teeth on
1. Is this the first time that you see the Crew member? Dental Chart Details:
dental chart below using the following Yes___ No___
symbols directly on the affected tooth:
Decay/Carry - ≠
2. Did you find the Crew Member's dental health to be in
Dental Filling - F
Broken/Fracture Tooth - Ɵ good standing?
Tooth Missing/Extracted - X
Yes____ or No___ (if no please explain)
_________________________________________________________
_________________________________________________________
_________________________________________________________

3. If there is dental work that will need to be done please

explain below.
__________________________________________________________
__________________________________________________________
__________________________________________________________

4. Overall, is this Crew Member clear of any cavities

or abcesses?
Yes ____ or No___ (if no please explain)
__________________________________________________________
__________________________________________________________

Note to Dentist: If there is work needed on patient, please elaborate in the notes section as to a time period. For
i.e., patient needs fillings, or patient needs root canal. It should state, " within the next six months or next year,
etc."
Notes: ____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

_______________________________________ Stamp/Seal Here:

I certify that I have examined the above Dentist's Name
named applicant. All findings of the x
examination have been reported above. Dentist’s Signature Date (__________)
Stamp/Seal Here

2018-06_ v 2
All Sea Medical LLC