Engine Room Staff Medical Eligibility Form
Personal Information
Full Name
Date of Birth
Rank/Position
Vessel Name
Nationality
Medical History
List any current or past illnesses
Are you currently taking any medication?
Any surgeries or injuries in the past?
Allergies
Do you smoke?
No
Yes
Do you consume alcohol?
No
Yes
Physical Examination
Height (cm)
Weight (kg)
Blood Pressure
Vision
Hearing
Other findings (if any)
Doctor's Assessment
Is applicant medically fit for Engine Room duties?
Fit
Unfit
Fit with conditions
Doctor's Remarks
Examining Doctor's Name
Date Examined