hrm@qr-catering.

eu

Record of Medical Examination Form

The presentation of a valid medical certificate from a registered medical practitioner declares that the
patient named below has been fully examined and is considered to be in good health and medically fit
for unrestricted duty on a hotel passenger vessel.
Possible later contract and any connected insurances may be considered INVALID if knowingly incorrect
information is given.

Name (first, middle, last): _________________________________________________________________

Date of birth (dd/mm/yyyy): ______/______/________

Sex: ____ Male ____ Female

Method of confirmation of identity, e.g. Passport No./ID Card No.: ______________________________

Position onboard: _________________________

Type of ship: River hotel ship

Trade area: The Netherlands

Employee's personal declaration (Assistance should be offered by medical staff)

I authorize the release of all my previous medical records from any health professionals, health
institutions and public authorities to Dr. __________________________________ (the approved medical
practitioner).

I hereby certify that the personal declaration below is a true statement to the best of my knowledge
and that I usually enjoy good physical and mental health. I understand that the non-disclosure or
suppression of any relevant facts known by me may prejudice my assignment, leading to the termination
of my employment.

Signature of employee: _______________________________

Date (dd/mm/yyyy): ______/______/________

Date and contact details for previous medical examination (if known): __________________________

Mailing address: Hondiusstraat 28B, 6827DE Arnhem, The Netherlands | 2024, v0

MEDICAL EXAMINATION FORM
 hrm@qr-catering.eu

Record of Medical Examination Form

Employee's personal declaration (Assistance should be offered by medical staff)

Have you ever had any of the following conditions*?

* It is strict Company policy that for the safety of mother and child not to assign pregnant women to river duty as
access to proper medical care can be limited onboard vessels – see Q16.

CONDITION YES NO IF YES GIVE DETAILS HERE

1 Infectious/contagious diseases

2 Operation/surgery

3 Stomach or intestinal disorders

4 Epilepsy/seizures

5 Dizziness/fainting/ Loss of consciousness

6 Diabetes

7 Depression, anxiety or nervous illness

8 Severe headaches

9 Balance problem

10 Restricted mobility/ Amputation

Back, neck or joint pain/
11
Fractures/Dislocations
12 Allergies/ Are you allergic to any medication?

13 Any kind of dermatitis or skin conditions?

14 Do you have any visible Tattoos or Piercings?

15 Do you smoke, use alcohol or drugs?

16 Are you currently pregnant?

Are you aware of having any medical

17
problems?
Do you feel healthy and fit to perform the
18
duties of your designated Position onboard?
Have you ever been declared unfit for
19
sea/river duty?

Mailing address: Hondiusstraat 28B, 6827DE Arnhem, The Netherlands | 2024, v0

MEDICAL EXAMINATION FORM
 hrm@qr-catering.eu

Record of Medical Examination Form

Assessment of fitness for service at sea / river
Medical practitioner's comments and assessment of fitness, with reasons for any limitations:

On the basis of the examinee's personal declaration and my clinical examination I declare the examinee
medically:

Fit for duty

Without restrictions
Not fit for duty
With restrictions (describe below if applicable)

Medical certificate’s date of issue (dd/mm/yyyy): ______/______/________

Signature of medical practitioner: ______________________________________

Medical practitioner information (name, licence number, address – official stamp):

__________________________________________________________________________

__________________________________________________________________________

Mailing address: Hondiusstraat 28B, 6827DE Arnhem, The Netherlands | 2024, v0

MEDICAL EXAMINATION FORM