Crew Medical Declaration Form
Full Name
Rank/Position
Vessel Name
Date of Birth
Nationality
Have you had any medical conditions in the last 12 months?
Are you currently taking any medication(s)? If yes, please specify.
Do you have any known allergies?
Have you undergone any surgery or operations in the past?
Other relevant medical information
I confirm the above information is accurate and complete to the best of my knowledge.
Crew Member Signature
Date