Prospective Crew Member Medical Questionnaire Please fill the form hereunder so you can join the yacht. First Name and Last Name * Email * Phone * Name of the yacht you are joining * Blood type * AB- B- AB+ A- O- B+ A+ O+ I don't know Please make sure this is accurate. When navigating in remote areas, this is the only way of knowing what blood type you are. Have you ever had any of the following conditions? * Any type of back injury or chronic back pain Eye/vision problem High blood pressure Heart/vascular disease Heart surgery Varicose veins/piles Asthma/bronchitis Blood disorder Diabetes Thyroid problem Digestive disorder Kidney problem Skin problem Allergies Infectious/contagious diseases Hernia Genital disorder Pregnancy Sleep problem Psychiatric problems Depression Attempted suicide Loss of memory Balance problem Severe headaches Ear (hearing, tinnitus)/nose/throat problem) Restricted mobility Back or joint problem Amputation Fractures/dislocations None of these If you answered “yes” to any of the above questions, please state the number associated with condition from the grid above and provide details: Do you use drugs? * Yes No In what quantities? * Do you use alcohol? * Yes No In what quantities? * Do we have your approval to submit you to random drugs an alcohol testing before and during the duration of your employment? * Yes No Do you smoke? * Yes No In what quantity? * Have you ever been signed off as sick or repatriated from a ship? * Yes No Please explain * Have you ever been hospitalized? * Yes No Please provide details * Have you ever been declared unfit for sea duty? * Yes No Please provide details * Has your medical certificate even been restricted or revoked? * Yes No Please provide details * Are you aware that you have any medical problems, diseases or illnesses? * Yes No Please provide details * Do you feel healthy and fit to perform the duties of your designated position/occupation? * Yes No Please provide details * Do you have any allergies? * Yes No Please provide the list everything you are allergic to, including medication and food. * Please list all the medications you are taking, the purpose(s) and dosage(s) Please check the vaccines that are NOT up to date * Cholera Hepatitis Polio Tetanos Typhoid Yellow Fever All my vaccines are up to date Have you been vaccinated against Covid-19? * Yes No Which vaccine did you receive? * Pfizer Moderna Janssen Astra Zeneca A Chinese vaccine Another vaccine Number of doses of the Covid-19 vaccine you received * - Select -1 dose2 doses3 doses4 doses5 doses Date latest dose was received * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2020202120222023202420252026202720282029 Any medical condition or medication? In case of emergency, these are the information we need to have in order for you to get the best medical care * Have you in the past ever made a claim for maintenance and/or cure against a Vessel owner upon which you were a crew member? * Yes No Please provide details * Consent * I agree to the privacy policy. I understand that this information will be shared with all the administrative personnel of my employer, yacht management company, first mate and captain, as well as any medical care provider.
