Cruise Ship Staff Pre-Sea Medical Screening Form
Personal Information
Full Name
Date of Birth
Nationality
Passport Number
Contact Number
Email Address
Medical History
Do you have any existing medical conditions?
Yes
No
If yes, please specify
Are you currently taking any medication?
Yes
No
If yes, please specify
Have you undergone any surgeries in the past?
Yes
No
If yes, please specify
Allergies (including medication, food, etc.)
Symptoms Check
Do you have or recently had any of the following symptoms?
Fever
Cough
Shortness of breath
Sore throat
Loss of taste or smell
Other
If "Other", please specify
Vaccination Details
Have you received all required vaccinations?
Yes
No
If no, which vaccination(s) are pending?
Date of last medical examination
Declaration
I hereby declare that the information provided above is true and complete to the best of my knowledge.
Signature
Date