Crew Medical Fitness Certificate

Personal Details
Full Name
Date of Birth
Nationality
Rank/Position
Vessel Name
Passport/ID No.
Medical Examination Summary
Height
Weight
Blood Pressure
Vision (Right/Left)
Hearing
Medical History & Findings
General Health:
Significant Illnesses:
Allergies:
Medications:
Fit for Duty
Date

Doctor's Name & Signature