Marine Personnel Health Evaluation Form
Complete this form to assess your health status for pre-deployment or routine onboard fitness screening. Please answer all questions accurately to ensure a safe and healthy work environment.
Full Name
*
First Name
Last Name
Position or Role Onboard
*
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently experiencing any of the following symptoms?
*
Fever or chills
Cough or sore throat
Shortness of breath
Muscle aches or fatigue
None of the above
Do you have any chronic medical conditions?
*
Cardiovascular disease
Respiratory disease (e.g., asthma, COPD)
Diabetes
None
Other
Are you currently taking any medications?
*
Yes
No
List any known allergies (medications, foods, environmental):
Fitness-to-Work Assessment
*
Fit for duty without restrictions
Fit for duty with restrictions
Not fit for duty
Additional Notes or Follow-Up Recommendations
Submit Evaluation
Should be Empty: