Offshore Platform Health Clearance Form
Personal Information
Full Name
Employee ID
Date of Birth
Position/Job Title
Department
Health History
Do you have any chronic illnesses?
Yes
No
If yes, please specify
Are you currently taking any medication?
Yes
No
If yes, please specify
Have you recently experienced any symptoms of illness?
Yes
No
If yes, please specify
Travel & Exposure History
Have you traveled internationally in the last 30 days?
Yes
No
If yes, countries visited
Have you been exposed to any contagious diseases?
Yes
No
If yes, please specify
Fitness Assessment
Height (cm)
Weight (kg)
Blood Pressure
Additional Remarks
Date
Signature