SEAFARER FIT TO TRAVEL MEDICAL CERTIFICATE

Surname:____________________________________________________________________

First name:___________________________________________________________________

Date of Birth:__________________________________________________________________

Sex: M F

Rank:_________________________________________________________________________

Indentity document__________________________N__________________________________

Examination date:_______________________________________________________________

I have examined the seafarer named above and confirm the following:

Past Medical History: not relevant

Current Medications: denies

HISTORY:

1)TYravelling to China, South Korea, UK, Japan, Iran, South Africa during last 14 days: YES NO

2)Fever YES NO

3)Cough YES NO

4)Shortness of breath YES NO

5)Contact with confirmed case of COVID-19 YES NO

GENERAL CONDITION

1) Blood pressuer_______mmHg SpO2_________% t________C

2) Respiratory system : Normal
3) Cardiovascular system: Normal
4) Gastrointestinal system: Normal
5) Nervous system: Normal
6) Mental system and cognitive function: Normal

The above named seafarer is in good physical and mental health and free fromany defector
disability during the examination on __________2021

During seafarer examination symptoms of COVID 19 were not detected

I certify that the above statements are complete to the best of my knowledge

Name of the Examiner:_______________________________________________

Signature of the Examiner:______________________