Yes

No

Have you ever signed off the ship due to medical reasons?

Have you undergone any operations in the past?

Have you suffered any accident/incident/injury which rendered you temporarily or partially disabled

Have you ever undergone psychiatric treatment of any kind?

Are you addicted to alcohol or drugs of any kind?

Have you ever been dismissed from the vessel for Alcohol or drug abuse?

Have you consulted a doctor during the last 12 months for any illness or accident?

Do you have any health, disability or concerns now?

Do you permanently take/use any medication and/or anything on prescription, prescribed by your doctor?

Did you suffer, or do you presently suffer from any disease likely to render you unfit for sea-service or likely to endanger your own health or the health of other persons onboard?