Yacht Crew Medical Fitness Disclosure
Name:
Position/Rank:
Passport/ID Number:
Date of Birth:
Medical History
Do you currently have or have you ever had any of the following? (Tick if Yes)
Asthma
Diabetes
Epilepsy
Heart Disease
Allergy
Other medical conditions or ongoing treatments:
Have you had any operations or been hospitalised in the past 5 years?
Are you taking any prescribed medications?
Have you had any injury or illness in the last 12 months that might affect your ability to work at sea?
Declaration
I declare that the information provided is true and complete to the best of my knowledge.
Signature:
Date: