Seafarer Personal Medical History Form

Personal Information

Full Name Date of Birth Nationality Passport/Seaman's Book No. Rank/Position Contact Number

Medical History

Have you ever had or do you currently have any of the following?

Condition	Yes	No	Details
Heart Disease / Hypertension
Lung Disease / Asthma
Diabetes
Tuberculosis
Epilepsy / Seizure disorders
Psychiatric Illness
Visual/Eye Problems
Hearing Problems
Kidney Disease
Hepatitis / Jaundice
Malaria / Tropical Diseases
Recent Surgical Procedures
Other significant illness or injuries

Current Medication

List any medication currently being taken

Allergies

List any allergies (including medicines, food, or others)

Declaration

I declare that the above information is true and complete to the best of my knowledge. Signature Date