Seafarer Chronic Condition Disclosure
Full Name
Rank / Position
Vessel / Company
Chronic Condition Details
Name of Chronic Condition
Date Diagnosed
Medication / Treatment (if any)
Attending Doctor / Clinic
Check-up Frequency
Work Limitations (if any)
Additional Remarks
Seafarer Declaration
I hereby declare that the information above is true and complete to the best of my knowledge.
Seafarer's Signature
Date