SYNERGYGROUP OPERATIONS INC.

MEDICAL HISTORY ASSESSMENT

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Seafarer: PALMA, RAPHAEL JERNAN PINCA
Last Name First Name Middle Name
4TH SINGL
Rank: ENGINEER Weight: 78 Kg: 78 Height: 167.5 Age: 24 Civil Status: E

Reason for Last Repatriation: [X] End Contract [ ] Accident [ ] Sickness

If Accident or Sickness: When _________________________ Where __________________________

Please Specify: __________________________________________________________________

MEDICAL HISTORY - Please put a check mark if you have ever suffered from or have been told that you have had the following conditions:

YES NO YES NO YES NO

1. Nose or throat trouble 12. Cancer or tumor 23. Sexually transmitted disease
2. Ear trouble or deafness 13. Mental disorder 24. Genetic of familial disorder
3. Chronic cough 14. Head or neck injury 25. Operations
4. Asthma 15. Hernia (rupture) 26. Malaria, if yes, date of last attack
5. Tuberculosis 16. Rheumatism, joints or back trouble 27. Tropical disease
6. Other lung disease 17. Fainting spells, fits or seizures 28. Frequent headache
7. High blood pressure 18. Typhoid or paratyphoid fever 29. Dizziness
8. Heart trouble 19. Trachoma or other eye trouble 30. Allergy
9. Rheumatic fever 20. Stomach pain or ulcer 31. HEPA B
10. Diabetes mellitus 21. Other abdominal trouble 32. Any intake of medication for
11. Endocrine disorder 22. Kidney or bladder trouble treatment of illness/es
33. Others: Pls use Remarks Section
REMARKS:

Last Recruitment Agency: PIC:

Date of Last Medical Examination: Clinic:
Be honest and truthful with your HEALTH DECLARATION (POEA Standard Terms & Condition)
RAPHAEL JERNAN P. PALMA
_____________________________________
Signature of Seafarer over Printed Name
SGOI/Rev00/Effective01.01.17/MHF