Fishing Vessel Crew Health Risk Self-Evaluation Form
Personal Information
Full Name
Date of Birth
Position on Vessel
Contact Information
Phone Number
Emergency Contact
Medical History
Heart Disease
Diabetes
Hypertension
Asthma
Allergies
Other Chronic Illness
Other Conditions / Details
Lifestyle & Risk Factors
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Physical Activity Level
Low
Moderate
High
Medications & Allergies
Current Medications (if any)
Known Allergies
Recent Symptoms (last 2 weeks)
Fever
Cough
Shortness of Breath
Headache
Fatigue
Other
If other, please specify
Remarks / Notes