Offshore Crew Medical Declaration Form
Personal Information
Full Name
Date of Birth
Position
Company
Passport/ID Number
Medical History
Have you ever had, or currently have, any of the following? (tick where applicable)
Asthma
Diabetes
Hypertension
Heart Disease
Epilepsy
Other
If "Other", please specify
Are you currently taking any medication?
No
Yes
If yes, please provide details
Have you undergone any surgery in the last 12 months?
No
Yes
If yes, give details
Have you suffered from any illness in the last 6 months?
No
Yes
If yes, give details
Do you have any known allergies?
No
Yes
If yes, please specify
I hereby declare that the above information is true and complete to the best of my knowledge. I understand that any false statement may affect my engagement or employment offshore.
Signature
Date