Maritime Crew Medical Self-Declaration
Personal Information
Full Name
Date of Birth
Nationality
Rank / Position
Passport No.
Seaman's Book No.
Medical History
Have you ever had or currently have any of the following?
Asthma or lung disease
Heart or circulatory disease
Diabetes
Epilepsy or seizures
Hearing problems
Vision problems (not corrected by glasses/lenses)
Mental health conditions
Other serious illness or injury
If you answered yes to any, please provide details
Medications
Are you currently taking any medications?
Yes
No
If yes, please list medications
Recent Illness or Symptoms
In the last 30 days, have you experienced any illness, injury, or symptoms (e.g., fever, cough, shortness of breath)?
Yes
No
If yes, please provide details
Declaration
I declare that the above information is true and complete to the best of my knowledge.
Signature
Date