Maritime Crew Health Assessment
Personal Information
Name
Rank/Position
Date of Birth
Nationality
Ship Name
Assessment Date
Medical History
Have you had any significant illnesses or surgeries?
Are you currently taking any medication?
Vaccination Status
Are your vaccinations up to date?
Yes
No
If no, specify which vaccines are missing
Health Assessment
Height (cm)
Weight (kg)
Blood Pressure
Vision
Hearing
Other findings or comments
Assessor's Information
Assessor Name
Assessor Signature
Date