Medical Questionnaire

This is where we need to know information that can be a bit awkward to share. But it is necessary. On any offshore passage if anything goes wrong you will be happy that you shared your medical information with us.This information we treat with respect. It will be kept on board in a sealed envelope and only used when necessary. At the end of the voyage we will hand you the envelope back or destroy it ourselves. In the case of a real emergency, the information you give us can save your life.

Name *

Date of Birth*

Age*

Gender*
MaleFemale

Which Course or Passage are you booked on?*

Do you have any existing medical conditions? Describe.*

Have you been hospitalized in last 5 years? Describe.*

Do you take regular medications? If yes, please list here:*

Do you wear glasses or contacts?*

Have you ever been seasick? Describe the worst sea conditions you've encountered.*

Have you suffered any gut problems? (Colitis, IBS, ulcers, etc.)*

Have you had counselling or medications for depression or other psychiatric conditions?*

Have you ever been treated for alcohol or drug abuse?*

Do you have any allergies?*

Do you have, or have you ever had: diabetes, epilepsy, high blood pressure, high cholesterol, cardiovascular disease, migraines, asthma or lung disease, any significant back, knee, foot or leg problems, or any other diseases or problems? *

Doctor's Name*

Doctor's Email

Doctor's Phone including country code (+X-XXX-XXX-XXXX)