Vessel Crew Medical Fitness Declaration
Crew Member Details
Full Name
Rank/Position
Date of Birth
Passport/Seaman Book Number
Nationality
Medical History
Heart Disease
Hypertension
Diabetes
Epilepsy
Asthma
Tuberculosis
Psychiatric Illness
Physical Impairment
Other
If any of the above are checked or any other condition exists, provide details
Current Health Status
Are you currently taking any medication?
Have you had any symptoms or medical issues in the last 6 months?
Declaration
Crew Member Signature
Date
Witness/Officer Signature
Date