Ship Crew Medical Self-Declaration
Personal Details
Full Name
Rank/Position
Date of Birth
Nationality
Health Status
Are you currently experiencing any of the following symptoms?
Fever
Cough
Shortness of Breath
Other
Do you have any chronic diseases?
None
Diabetes
Hypertension
Heart Disease
Other
Are you currently taking any medication? If yes, please specify.
Declaration
I hereby declare that the above information is true and complete to the best of my knowledge.
Date
Signature