Offshore Medical Fitness Form
Complete this form to provide the medical and work-related details needed to assess offshore fitness for duty.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Employer/Company Name
*
Job Title/Position
*
Intended Offshore Assignment/Location
*
Offshore Work Details
Offshore vessel/platform/site name
*
Expected deployment date
*
-
Month
-
Day
Year
Date
Assignment duration (days)
*
Type of offshore work / role
*
Please Select
Deck crew
Engineering
Maintenance
Drilling
Marine operations
HSE/Safety
Medical/Support
Other
Medical History and Current Health Status
Current symptoms or health concerns
Chronic conditions
Heart disease
Hypertension
Diabetes
Asthma
Other respiratory condition
Seizures/Epilepsy
None
Other
History of heart disease
*
Yes
No
Not sure
History of hypertension
*
Yes
No
Not sure
History of diabetes
*
Yes
No
Not sure
Asthma or other respiratory condition
*
Yes
No
Not sure
History of seizures or epilepsy
*
Yes
No
Not sure
Episodes of fainting or dizziness
*
Yes
No
Not sure
Recent surgery or hospitalization
*
Yes
No
Not sure
Date of last medical examination
-
Month
-
Day
Year
Date
Lifestyle and Occupational Fitness Factors
Smoking Status
*
Never
Former
Current
Prefer not to say
Alcohol Use
None
Occasional
Regular
Prefer not to say
Physical Work Conditions You Can Safely Perform
*
Physically demanding tasks
Working at heights
Working in confined spaces
Shift work
Swimming ability
Sea travel tolerance
Ability to Perform Physically Demanding Tasks
*
Unable
1
2
3
4
5
6
7
8
9
Fully able
10
1 is Unable, 10 is Fully able
Fitness for Offshore Work Conditions
*
1
2
3
4
5
Additional Fitness Limitations or Concerns
None
Motion sickness
Dizziness
Claustrophobia
Fear of heights
Reduced stamina
Other
Emergency and Physician Information
Emergency Contact Name
*
First Name
Last Name
Relationship to Applicant
*
Please Select
Spouse
Parent
Sibling
Child
Partner
Friend
Other
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Treating Physician / Clinic Name
Medical Declaration and Authorization
Applicant Signature
*
Submit
Submit
Should be Empty: