Skip to content
+1-954-500-0405
|
cr@121yachts.com
About Us
Why Choose One2One YM
Savings Calculator
Crew Quarter
Contact Us
With us, you are not just a number, the are THE One.
Search for:
HOME
CREW
FINANCE
ADMINISTRATION
REGISTRATION
TECHNICAL
ISM-ISPS
Yacht Crew Medical Questionnaire
Yacht Crew Medical Questionnaire
admin
2021-04-07T23:25:53-04:00
Please fill the form hereunder so you can join the yacht.
Prospective Crew Member Medical Questionnaire
Medical Questionnaire
First Name and Last Name
*
Name of the yacht you are joining
*
Blood type
*
AB-
B-
AB+
A-
O-
B+
A+
O+
I do not 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
*
1 dose
2 doses
3 doses
Date latest dose was received
*
Month
Day
Year
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.
CAPTCHA