Crew Medical Declaration Form
Full Name
Date of Birth
Nationality
Rank/Position
Vessel Name
Have you had any of the following? (Check all that apply)
Diabetes
Hypertension
Asthma
Heart Disease
Other
If you answered yes to any above, please provide details
Are you currently taking any medication?
Yes
No
If yes, please list medications
Have you had any symptoms of illness in the past 14 days?
Yes
No
If yes, describe symptoms
Additional Notes
Signature
Date