Medical Examination Certificate

sea chefs River Cruises Ltd

CONFIDENTIAL
TO BE COMPLETED IN ENGLISH CAPITAL LETTERS

First &
Surname:
Middle Name/s:
Date of Birth: Passport No: Male
Gender:
Place of Birth: Nationality: Female

Contact Address: Telephone Number:

Email Address:

Personal Declaration of Health

YES NO
1. Have you been hospitalized at any time? if so when and for what reason?
Have you suffered from Heart/Vascular Disease, cerebral disorder, nervous disorder or any
2.
other condition?
3. Have you at any time required surgery?
4. Have you at any time suffered an injury as a result of an accident?
5. Have you at any time suffered from any form of disability?
6. Have you suffered any Illness or are aware of any medical condition?
7. Are you on any medication for any medical disorder
8. Do you feel healthy and fit to perform the duties of your designated position / occupation?
If any of the above questions were answered “YES”, please give the question number and full details on a separate page

Medical Examination
Height: Cm Weight Kg
Pulse Rate ( / minute) Rhythm
Blood Pressure
mm Hg Diastolic mm Hg
Systolic
Urinalysis Glucose Protein
Chest X-Ray (Tuberculosis)

Normal Abnormal Not performed

Sight, Color Vision and Hearing

Speech and
Visual Fields Normal Defective Normal Whisper
Whisper Test
Right Eye Right Ear
Left Eye Left Ear
Colour Vision Normal Doubtful Defective

For Food Handlers

Salmonella Test Results: Not Performed Performed

Assessment of Fitness
On the basis of the examinee’s person declaration, my clinical examination and the diagnostic test results recorded
above, I declare the Examinee medically: FIT FOR DUTY NOT FIT FOR DUTY

Date of Examination:
Stamp of Physician
Name of Physician:

Signature of Physician:

F6.6 Medical Examination/Certificate Issue: 6/ Issue date: 18.11.20 / 1/2

Medical Certificate is valid for one year
 Medical Examination Certificate

sea chefs River Cruises Ltd

CONFIDENTIAL
TO BE COMPLETED IN ENGLISH CAPITAL LETTERS

F6.6 Medical Examination/Certificate Issue: 6/ Issue date: 18.11.20 / 2/2

Medical Certificate is valid for one year