Seafarer Health Assessment Form
Complete this form to provide a comprehensive assessment of your general health and fitness for duty as a seafarer.
Full Name
*
First Name
Last Name
Seafarer Role/Position
*
Please Select
Deck Officer
Engineer
Cook
Able Seaman
Oiler
Steward
Other
Current Assignment/Ship Name
*
How would you rate your overall health in the past week?
*
1
2
3
4
5
Have you experienced any of the following symptoms recently? (Select all that apply)
*
Fever
Cough
Shortness of breath
Fatigue
Muscle aches
Headache
None of the above
Other
Please indicate if you have a history of any of the following medical conditions:
*
Rows
Yes
No
Hypertension
1
2
Diabetes
3
4
Asthma
5
6
Heart disease
7
8
Epilepsy
9
10
None of the above
11
12
Are you currently taking any medications?
*
Yes
No
If yes, please list your current medications (name and dosage):
How would you rate your current fitness to perform your assigned duties?
*
Not fit
1
2
3
4
Fully fit
5
1 is Not fit, 5 is Fully fit
Additional comments or relevant health information:
Submit Assessment
Should be Empty: