Vessel Cook Medical Fitness Statement
Personal Information
Name:
Date of Birth:
Nationality:
Rank/Position:
Vessel Name:
Medical Examination
1. General Health Status:
2. Vision:
3. Hearing:
4. Cardiovascular System:
5. Respiratory System:
6. Musculoskeletal System:
7. Skin Condition:
8. Other Relevant Findings:
Fit for Duty Statement
The above-named individual has been examined and found (choose one):
Fit for duty
Unfit for duty
Fit with restrictions
If restrictions, specify:
Examiner's Details
Name of Examiner:
Position:
License/Registration No.:
Date:
Signature of Examiner:
Stamp: