Book Appointment Seafarers Form

Kamat Commercial, Margao, Goa. INDIA. 403601 +91 9011412574/ +91 8698708536 drdivinemedicals@yahoo.co.in

Seafarers Form

Home - Seafarers Form

Find Your Saved Form

Enter your Passport No to access your saved form.

Personal Details

First Name / Given Name *

Middle Name

Last Name / Family Name *

Age

Date of Birth

Gender

Marital Status

Nationality

Phone Number *

Email ID

Address

Seafarer / Employment Details

Company Name

Ship Name

Type of Ship

Position / Rank

Department

Identification Details

Passport No*

Crew ID /Emp ID

INDOS NO.

Medical Basic Information

Medical Date

Blood Group

Colour of Eyes

Identification Mark

Examinee’s Personal Declaration

Have You Ever Had Any Of The Following Condition?

No.	Condition	Yes	No
1	Eye/Vision problems
2	High Blood Pressure
3	Heart/Vascular Disease
4	Heart Surgery
5	Varicose Veins
6	Asthma/bronchitis
7	Blood Disorder
8	Diabetes
9	Thyroid Problem
10	Digestive Disorder
11	Kidney Problem
12	Skin Problem
13	Allergies
14	Infectious/Contagious Diseases
15	Hernia
16	Genital Disorders
17	Pregnancy
18	Sleep Problems
19	Do you smoke?
20	Operation/surgery
21	Epilepsy/seizures
22	Dizziness/fainting
23	Loss of Consciousness
24	Psychiatric Problems
25	Depression
26	Attempted Suicide
27	Loss of Memory
28	Balance Problem
29	Severe Headaches
30	Ear/nose/throat problems
31	Restricted Mobility
32	Back Problems
33	Amputation
34	Fractures/dislocations
35	Do you consume alcohol?
36	Are you suffering from any Malignancy
37	Have you ever been signed off as sick or repatriated from a ship?
38	Have you ever been hospitalized?
39	Have you ever been declared unfit for sea duty?
40	Has your medical certificate ever been restricted or revoked?
41	Are you aware that you have any medical problems, diseases or illnesses?
42	Do you feel healthy and fit to perform, the duties of your designated position/occupation?
43	Are You Allergic to any medication?
44	Are you taking any non-prescription or prescription medications?

If any of the above questions were answered "Yes", please give details

If yes, please list the medications taken and the purpose(s) your dosage(s)

Get In Touch

DIVINE MEDICAL CENTRE Kamat Commercial, Near Hari Mandir, Margao, Goa.

drdivinemedicals@yahoo.co.in

+91 9011412574/ +91 8698708536

Quick Links

Home About Us Our Services Facilities Contact Us