Sundhedsbevis for søfarende (engelsk)

DANISH MARITIME AUTHORITY

Medical certificate for examinations of seafarers
Parts A and B to be completed by the seafarer
To be used only for persons of 16 years of age or older
Name

First name(s)Surname
Date of birth in format day-month-year

MonthDayYear
Date
Sex (M/F)
Occupation
Nationality
Address

Home address street house number

Street Address Line 2

Postal code and town/cityState / Province

Postal / Zip CodeCountry
B. OWN DECLARATION

	No	Yes	When (year)
Have you previously served in Danish ships?
Have you previously undergone a medical examination for seafares?
Have you been declared unfit for sea service or fit subject to limitations at any previous medical examination?
Have you been admitted to hospital?
Have you within the last two years had unbroken periods of sick leave and more than 30 days?
Do you have difficulties in orientating yourself under reduced lighting?

Do you suffer or have you suffered from any of the following diseases?

	No	Yes	When (year)
Lung diseases, including pulmonary tuberculosis (TB)?
Stomach and internal diseases including gastric ulcer?
Heart and circulatory diseases?
Kidney and bladder diseases?
Diabetes?
Ear diseases?
Eye diseases?
Pain in the back including lumbago and sciatica?
Epilepsy or other convulsive fits?
Alcohol- and drug abuse for which you have been treated?
Hypersensitive reactions, including asthma?
Eczema?
Serious accidents causing permanent disability?
Do you use medicine regularly?
Mental disorders for which you have received medical treatment?

I hereby give my consent that information about any previous diseases may be obtained from doctors, hospital, other treatment centers and public authorities
Date

MonthDayYear
Date
Seafarers signature

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