SURNAME – NOM            FIRST NAME AND INITIALS – PRENOM ET INITIALES

Bloggins,   Henry 

PRI/SN – CIDP/NM   

   R01 986 025  

RANK/GRADE

PO1           

DOB – DDN

Unknown             

MOC – GPM

314

PARENT UNIT – UNITE D’APPARTENANCE

HMCS Lolypop 

REFERRED TO – MEDICIN CONSULTANT                           

Senior Surgeon                                           

DATE

UNIT AND/OR ADDRESS OF REFERRED CONSULTANT – UNITE  ET/OU ADRESSE OU MEDICIN CONSULTE

SUMMARY OF COMPLAINTS – RESUME DES SYMPTOMES 

42 to 60 year old sailor, just about to get promoted to CPO2, requires to have spine removed and replaced with flexible material such as garden hose, please schedule for surgery ASAP

SIGNATURE OF MO I/C CASE

SHIP’S DOC

CONSULTANTS REPORT – RAPPORT DU MEDICIN CONSULTANT

ACTION

MO’s INITIALES        

Yes   

No

DIAGNOSIS

RECOMMENDATIONS – RECOMMANDATIONS

CONSULTANT’S SPECIALTY

NAME AND INITIALS

SIGNATURE

DATE