Medical Examinations of Seafarer Record Form
Part A
To be completed by the seafarer who is responsible for answering each question accurately.
Seafarer's Name in Full:
First Name
Last Name
Sex:
*
Please Select
Male
Female
Date:
*
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Place of Birth:
*
Nationality:
*
Type of ID Documents: NRIC Number / Passport Number:
*
Department:
*
Please Select
Deck
Engine
Catering
Others
Rank:
*
Type of Ship:
*
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Routine and Emergency Duties:
*
Trading area:
*
e.g. coastal/tropical/worldwide
Seafarer’s Declarations (please tick)
Have you ever had any of the following conditions?
*
Rows
Yes
No
1. Eye / vision problem
1
2
2. High blood pressure
3
4
3. Heart/ vascular disease
5
6
4. Heart surgery
7
8
5. Varicose veins / piles
9
10
6. Asthma / bronchitis
11
12
7. Blood disorder
13
14
8. Diabetes
15
16
9. Thyroid Problem
17
18
10. Digestive Problem
19
20
11. Kidney Problem
21
22
12. Skin Problem
23
24
13. Allergies
25
26
14. Infectious / Contagious Diseases
27
28
15. Hernia
29
30
16. Genital Disorder
31
32
17. Pregnancy
33
34
18. Sleep Problem
35
36
19. Do you smoke, use alcohol or drugs?
37
38
20. Operation / Surgery
39
40
21. Epilepsy / Seizures
41
42
22. Dizziniess / fainting
43
44
23. Loss of consicousness
45
46
24. Psychiatric problems
47
48
25. Depression
49
50
26. Attempted Suicide
51
52
27. Loss of Memory
53
54
28. Balance Problem
55
56
29. Severe Headaches
57
58
30. Ear (hearing,tinnitus) / nose / throat problem
59
60
31. Restricted Mobility
61
62
32. Back or joint problem
63
64
33. Amputation
65
66
34. Fractures / Disclocations
67
68
If you answered 'yes' to any of the above questions, please give details:
Additional Questions
Rows
Yes
No
35. Have you ever been signed off as sick or repatriated from a ship?
69
70
36. Have you ever been hospatilzed?
71
72
37. Have you ever been declared unfit for sea duty?
73
74
38. Has your medical certificate even been restricted or revoked?
75
76
39. Are you aware that you have any medical problems, diseases or illnesses?
77
78
40. Do you feel healthy and fit to perform the duties of your designated position / occupation?
79
80
41. Are you allergic to any medication?
81
82
42. Are you taking any non-prescription or prescription medication?
83
84
If 'yes' please list the medications taken, and the purpose(s) and dosage(s):
I hereby certify that the personal declaration above is a true statement to the best of my knowledge
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
85
Signature of Seafarer
Name of Witness
Signature of Witness
Continue
Continue
Should be Empty: