Cruise Ship Passenger Health Declaration
Personal Information
Full Name
Date of Birth
Passport Number
Cabin Number
Nationality
Health Information
Have you experienced any of the following symptoms in the last 14 days? (Fever, cough, sore throat, difficulty breathing, loss of taste or smell)
No
Yes
If yes, please specify:
Do you have any chronic medical conditions? (e.g. diabetes, heart disease, respiratory illness, immunodeficiency)
No
Yes
If yes, please specify:
Exposure Declaration
Have you been in contact with any confirmed cases of communicable diseases in the last 14 days?
No
Yes
If yes, please specify:
Date
Signature