Seafarer Pre-Employment Medical Fitness Declaration Form

Personal Information

Medical History

Condition	Yes	No	Details (if any)
Cardiovascular Disease
Hypertension
Diabetes
Epilepsy or Seizures
Asthma or Respiratory Disorders
Visual or Hearing Impairment
Other (please specify)

Have you ever been hospitalized or had any surgery? Are you currently taking any medication?

Declaration

I hereby declare that I have answered all questions truthfully and to the best of my knowledge. I understand that any false statements may lead to disqualification of employment.