Yacht Crew Medical Questionnaire - One-to-One Yacht Management

First Name and Last Name*

Name of the yacht you are joining*

Blood type*

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?*

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*

1 dose
2 doses
3 doses

Date latest dose was received*

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.

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With us, you are not just a number, the are THE One.

Prospective Crew Member Medical Questionnaire