Fishing Vessel Crew Medical Declaration Form
Vessel Name
Voyage Date
Crew Member Information
Full Name
Position/Rank
Date of Birth
Nationality
Passport/ID Number
Medical Declaration
Do you currently suffer from any illness or injury?
Yes
No
If yes, please provide details
Are you taking any medication?
Yes
No
If yes, please provide details
Have you had any surgery or hospitalization in the past year?
Yes
No
If yes, please provide details
Other relevant medical conditions or allergies
Emergency Contact Name
Relationship
Emergency Contact Phone
Declaration
I declare that the information provided above is true and complete to the best of my knowledge.
Crew Member Signature
Date