Format For Recording Medical Examinations Of Seafarers (Page 2 of 4) in pdf

Format For Recording Medical Examinations Of Seafarers Page 2

Additional questions

YES

35. Have you ever been signed off as sick or repatriated from a ship?

36. Have you ever been hospitalized?

37. Have you ever been declared unfit for sea duty?

38. Has your medical certificate ever been restricted or revoked?

39. Are you aware that you have any medical problems, diseases or illness?

40. Do you feel healthy and fit to perform the duties of your designed position/occupation?

41. Are you allergic to any medications?

Comments:

42. Are you taking any non-prescription or prescription medications?

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.

Signature of examinee: _______________________________________________________________

Date (day/month/year):

Witnessed by:

Name: (typed or printed):

I hereby authorize the release of all my previous medical records from any health professionals,

health, institutions and public authorities to Dr.

(the approved

medical practitioner).

Signature of examinee: _______________________________________________________________

Date (day/month/year):

Witnessed by: (Signature): ___________________________________________________________

Name: (Typed or printed):

Date and contact details for previous medical examination (if known):

F-ALM-011

Rev. 03

Page 2 de 4

Date: 13/03/2013.

Format For Recording Medical Examinations Of Seafarers Page 2