Pre-Sea Medical History Questionnaire
Personal Information
Full Name
Date of Birth
Nationality
Rank/Position
Contact Number
Medical History
Have you ever had, or have you currently:
Asthma
Diabetes
Epilepsy
Heart Disease
High Blood Pressure
Tuberculosis
Hepatitis
Malaria
Psychiatric Disorders
Other (specify below)
If other, please specify
Surgical History
Have you ever undergone any operations?
Yes
No
If yes, please specify
Allergies
Do you have any allergies (medications, food, etc.)?
Yes
No
If yes, please specify
Current Medications
Are you currently taking any medication?
Yes
No
If yes, please list
Additional Information
Any other relevant medical information:
Date
Signature