Engine Room Crew Pre-Sea Health Assessment
Personal Information
Full Name
Date of Birth
Rank/Position
Nationality
Date of Assessment
Medical History
Previous illnesses, surgeries, or hospitalizations
Current medications
Known allergies
Physical Examination
Parameter
Result
Remarks
Height (cm)
Weight (kg)
Blood Pressure
Vision
Hearing
Lung Function
Cardiac Exam
Fit for Duty Assessment
Is the crew member fit for duty?
Fit
Unfit
Fit with conditions
Comments/Restrictions
Examined by (Physician Name & Signature)
Date