U.S. Coast Guard Form CG-719K, Application for Medical Certificate Completed Form Examples and Samples

Explore comprehensive, filled-out examples of the U.S. Coast Guard Form CG-719K, Application for Medical Certificate. Our detailed samples guide mariners on how to correctly complete the form for various endorsements and medical conditions, ensuring a smooth application process.
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Completed U.S. Coast Guard Form CG-719K for a Deck Officer's medical certificate renewal.

CG-719K Example – Deck Officer Medical Renewal

How this form was filled:

This example demonstrates how our AI can process a mariner's dictated pre-examination notes to accurately complete the extensive CG-719K medical application. The AI intelligently extracted personal details, a complex medical history including chronic conditions like hypertension and sleep apnea, current medications, and vision requirements from a single unstructured narrative.

Source document used: Mariner's Pre-Exam Dictation Notes

Okay, notes for my appointment with Dr. O'Malley on Tuesday, March 7th, 2026. This is for my Coast Guard medical certificate renewal, Form CG-719K. My full name is William Patrick Harrison, and my Mariner Reference Number is 7654321. My birthday is June 15, 1978. I need this for my Deck Officer credential. They can mail everything to my home at 450 Ocean Drive, Fort Lauderdale, FL 33301. My cell is the best way to reach me at 954-555-1234, or my email [email protected].

For the medical history part, the main things are my blood pressure and my sleep apnea. The hypertension was diagnosed back in 2018, but it's been totally stable on my current meds. I take one Lisinopril, 10 mg, every morning. My blood pressure at home is usually around 128 over 82. The other big one is the obstructive sleep apnea, which they found in 2020. I've been using my CPAP every night since, and I have the compliance reports to prove it. I need to make sure she notes that. I also get some seasonal allergies, and I take Loratadine 10mg when they flare up, but it's not a big deal. Oh, and I had a minor back strain from lifting in 2022, but it's been a non-issue for years, no pain or limitations now. Everything else is pretty clear. No surgeries, no other major issues.

For the physical exam part, my height is 5'10", so 70 inches. Weight is about 220 pounds these days. My vision isn't perfect; I wear glasses for distance. Without them, it's probably 20/50, but with them, I'm 20/20 in both eyes. Color vision is fine, never had a problem. Hearing is good. I'm active and can handle all the physical duties on board, no problem. I just need to get this form signed off so I can submit my renewal package to the NMC.

Information used to fill out the document:

  • Applicant: William Patrick Harrison, DOB 06/15/1978
  • Contact Information: 954-555-1234, 450 Ocean Drive, Fort Lauderdale, FL 33301
  • Mariner ID: Reference Number: 7654321
  • Endorsement: Deck Officer
  • Medical Conditions: Hypertension (2018), Obstructive Sleep Apnea (2020), Seasonal Allergies, Back Strain (2022, resolved)
  • Medications: Lisinopril 10mg daily (Hypertension), Loratadine 10mg as needed (Allergies)
  • Physical Vitals: Height: 70in, Weight: 220lbs, BP: 128/82
  • Vision: Uncorrected 20/50, Corrected to 20/20

What this filled form sample shows:

  • Identified and parsed multiple medical conditions with diagnosis dates from a narrative flow
  • Extracted medication names, dosages, and frequencies, linking them to their respective conditions
  • Distinguished between uncorrected and corrected vision values mentioned conversationally
  • Correctly mapped the Mariner Reference Number from the text
  • Calculated the Body Mass Index (BMI) from height and weight data provided in the source

Form specifications and details:

Use Case: Medical Certificate Renewal for Deck Officer
Source Document: Mariner's Pre-Exam Dictation Notes
Form: U.S. Coast Guard Form CG-719K (03/25)
Keywords: how to fill U.S. Coast Guard Form CG-719K, Application for Medical Certificate example, CG-719K sample, mariner medical certificate
Categories: medical forms, Coast Guard forms, medical certificate forms, VA medical forms, Medi-Cal forms
Created: March 10, 2026 03:53 AM
Completed U.S. Coast Guard Form CG-719K for a Deck Officer's medical certificate renewal.