Seafarer Pre-Boarding Health Assessment Sheet
Personal Information
Name
Age
Gender
Male
Female
Other
Rank/Position
Vessel Name
Date
Vital Signs
Height (cm)
Weight (kg)
Blood Pressure (mmHg)
Pulse Rate (bpm)
Temperature (°C)
Medical History
Do you have any of the following? (Check all that apply)
Yes
No
Hypertension
Diabetes
Asthma
Allergies
Other
Symptoms Check
Are you currently experiencing any of the following?
Symptom
Yes
No
Fever
Cough
Sore Throat
Shortness of Breath
Other
Travel and Exposure History
Have you traveled internationally in the last 14 days?
Yes
No
If yes, list countries visited
Have you been in contact with a confirmed case of infectious disease?
Yes
No
If yes, provide details
Remarks
Assessment By Medical Personnel
Name
Date
Signature