• YEHS - CRUISE LINES PEME FORM

    This PEME form is for Royal Caribbean and Virgin
  • When is your appointment? (Enter time in 12 hour mode)*
     - -
  • Do you want a reciept for this assessment?*
  • Would you like any vaccinations at your appointment?*
  • What vaccinations would you like?

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - CRUISE LINES PEME FORM

    YOUR DETAILS
  • Birth Date (day month year)*
     / /
  • Gender Assigned at Birth*
  • Format: 00000000000.

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - CRUISE LINES PEME FORM

  • Which Cruise Line PEME are you having?*
  • Please tick all options that apply (Virgin Crew)
  • Please tick all options that apply (Royal Caribbean Crew)
  • Contract?*

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - VIRGIN CRUISE LINE PEME FORM

    Section A - Personal Medical History

  • Ear, Nose & Throat (ENT)

  • 1.⁠ ⁠Do you have or had Frequent Ear Infection?
  • 2.⁠ ⁠Do you have or had Hearing Problems or lost?
  • 3.⁠ ⁠Do you have or had sinus trouble?
  • 4.⁠ ⁠Do you have or had frequent nosebleeds?
  • 5.⁠ ⁠Do you have or had Frequent Colds?
  • 6.⁠ ⁠Do you have or had Frequent Sore Throats?
  • 7.⁠ ⁠Do you have or had Balance Problems?
  • 8.⁠ ⁠Do you have or had Vertigo?
  • 9.⁠ ⁠Do you have or had Meniere’s Disease?
  • 10.⁠ ⁠Do you have or had Spinning Sensation?

  • Cardiology

  • 1. Do you have or had high blood pressure?
  • 2. Do you have or had low blood pressure?
  • 3. Do have or had a heart attack?
  • 4. Do you have or had angina?
  • 5. Do you have or had an irregular heartbeat?
  • 6. Do you have or had poor circulation?
  • 7. Have you had a stroke?
  • 8. Do you have or had paralysis?
  • 9. Other heart disease?

  • Psychiatric

  • 1. Do you have or had depression?
  • 2. Do you have or had anxiety?
  • 3. Do you have or had thoughts of harming self or others?
  • 4. Have you ever attempted suicide?
  • 5. Have you ever had a nervous breakdown?
  • 6. Do you have Attention Deficit Disorder? (ADD)
  • 7. Do you have Attention Deficit Hyperactivity Disorder(ADHD)?
  • 8 Have you received treatment from a mental health professional?
  • 9. Have you ever had psychological/psychiatric illness or disorder?
  • 10. Do you have or had trouble sleeping or staying asleep?
  • 11. Have you ever treated for drugs, alcohol or substance abuse?
  • 12. Have you ever taken antidepressant medication?
  • 13. Have you ever been diagnosed with bipolar disorder?
  • 14. Have you ever been diagnosed with Schizophrenia?
  • 15. Have you ever had Post Traumatic Stress Disorder (PTSD)?
  • 16. Do you have any pre-existing medical and/or mental health/psychological conditions that have not been covered in this questionnaire?
  • 17. Have you ever been declared or certified unfit for work for any reason, including but not limited to health, injuries, mental health, or psychological counselling?
  • 18. Have you ever been admitted to a hospital because of illness, injury or mental health/psychological episodes or conditions?
  • 19. Have you ever had obsessive compulsive disorder?

  • Vision/Ophthalmology

  • 1. Do you wear glasses or contact lenses?
  • 2. Do you have or had Eye Injury and/or illness?
  • 3. Do you have or had Conjunctivitis?
  • 4. Do you have or had Glaucoma?
  • 5. Do you have or had eye or vision problems?
  • 6. Do you have or had cataracts?
  • 7. Do you have or had eye surgery?
  • 8. Do you have or had color blindness?
  • 9. Do you have or had macular degeneration?
  • 10. Do you have or had Chalazion (eyelid cysts)?

  • Pulmonary

  • 1. Do you have or had Swollen Lymph Nodes?
  • 2. Do you have or had Asthma?
  • 3. Do you have or had Wheezing?
  • 4. Do you have or had Bronchitis?
  • 5. Do you have or had Tuberculosis?
  • 6. Do you have or had Pneumonia?
  • 7. Do you have or had Cough up Blood?
  • 8. Do you have or had Shortness of Breath?
  • 9. Do you have or had Pulmonary Embolism?
  • 10. Do you have or had Sleep Apnea?
  • 11. Do you have or ever had lung injury or illness?
  • 12. Do you have or ever had a collapsed lung?
  • 13. Do you have or ever had Pulmonary Fibrosis?

  • Endocrinology

  • 1. Do you have or had diabetes? Type 1 or Type 2
  • 2. Do you have or had osteoporosis?
  • 3. Do you have or had thyroid disorder or disease?
  • 4. Do you have or had problems with weight loss or gain?
  • 5. Have you had any other Endocrinology disease or disorder?
  • 6. Do you have or had hormone disease or disorder?
  • 7. Do you have or had prolong tiredness?
  • 8. Have you had sensitivity to temperatures (too cold or toohot)?
  • 9. Do you have or had any autoimmune diseases?
  • 10. Did you have or had Gestational Diabetes?

  • Dermatology

  • 1. Do you have or had skin problems and rash?
  • 2. Do you have or had dermatitis?
  • 3. Do you have or had psoriasis?
  • 4. Do you have or had eczema?
  • 5. Do you have or had latex gloves allergies?

  • Infectious Diseases

  • 1. Do you have or had Rheumatic Fever?
  • 2. Do you have or had infectious diseases?
  • 3. Do you have or had contagious diseases?
  • 4. Do you have or had syphilis?
  • 5. Do you have HIV?
  • 6. Do you have or had Gonorrhea?
  • 7. Do you have or had HPV?
  • 8. Do you have or had sexual transmitted diseases?
  • 9. Do you have or had any type of hepatitis?
  • 10. Have you had any type of tropical diseases?
  • 11. Do you have or had COVID-19?
  • 12. Do you have or had Dengue or Malaria?
  • 13. Do you have or had Mononucleosis?
  • 14. Do you have or had Chicken Pox?
  • 15. Do you have or had Measles?
  • 16. Do you have or had Mumps?
  • 17. Do you have or had Zika?

  • Oncology

  • 2. 1. Do you have or have you ever had cancer?
  • 2. Do you have or have you ever had tumors?
  • 3. Have you had treatment for cystic disease?
  • 4. Have you had treatment for colon/rectal cancer?
  • 5. Have you had treatment for myoma?
  • 6. Have you had treatment for skin lesions?
  • 7. Have you had tenderness, mass, lumps, cysts, tumours, or cancer in your breasts?
  • 8. Do you have or had fibroids, ovarian cysts, tumors or cancer?
  • 9. Have you had treatment for mixed cancers?
  • 10. Have you had treatment for prostate cancer?

  • Urology

  • 1. Do you have or had Kidney Stones?
  • 2. Do you have or had any type of kidney problem?
  • 3. Do you have or had kidney or bladder infections?
  • 4. Do you have or had kidney cysts?
  • 5. Do you have or had blood in urine?
  • 6. Do you have or had urinary tract infections?
  • 7. Do you have or had prostate diseases (Males)?
  • 8. Do you have or had bladder problems?

  • Gastroenterology

  • 9. 1. Do you now have or have you ever had Gastritis?
  • 2. Do you have or had Gallbladder stones or polyps?
  • 3. Do you have or had Gallbladder polyps?
  • 4. Have you ever had Anal Fissures?
  • 5. Do you have or had any type of Ulcers?
  • 6. Do you have or had Abdominal Pains?
  • 7. Do you have or had chronic diarrhea?
  • 8. Do you have or had episodes of prolong constipation?
  • 9. Do you have or had gluten intolerance?
  • 10. Do you have or had bleeding from stomach?
  • 11. Do you have or had bleeding from bowels?
  • 12. Do you have or had irritable bowel syndrome?
  • 13. Do you have or had Hemorrhoids?
  • 14. Do you have or had Jaundice?
  • 15. Do you have or had Liver Problems/Disease?
  • 16. Do you have or had any type of hernia?
  • 17. Do you have Crohn's disease?

  • Disability

  • 1. Have you ever been declared partially disabled?
  • 2. Have you ever been declared fully disabled?

  • Neurology

  • 1. Do you have or had headaches lasting more than 4 hours?
  • 2. Do you have or had migraines?
  • 3. Do you have or had loss of consciousness?
  • 4. Do you have or had episodes of dizziness?
  • 6. Do you have or had any type of head injury?
  • 7. Do you have or had concussions?
  • 8. Have you ever had fainting spells?
  • 9. Have you ever had seizures or epilepsy?
  • 10. Do you have or had any neurological disorder?
  • 11. Have ever had a stroke(s)? including mini-strokes?
  • 12. Do you have or had muscle weakness or loss of sensation?

  • Blood Disorders

  • 1. Do you have or had anemia including sickle cell anemia?
  • 2. Do you have or had hemophilia?
  • 3. Do you have or had Leukemia?
  • 4. Do you have orhad sickle cell anemia?
  • 5. Do you have or had sickle cell trait?
  • 6. Do you haveor had any other blood disorder?
  • 7. Do you have or had Polycythemia Vera?

  • Orthopedics

  • 1.Do you now have or have you ever had Bone pain?
  • 2. Do you now have or have you ever had Neck pain or injury?
  • 3. Do you now have or have you ever had Shoulder pain or injury?
  • 4. Do you now have or have you ever had Mid Back pain or injury?
  • 5. Do you now have or have you ever had Low Back pain or injury?
  • 6. Do you now haveor have you ever had Radiating pain?
  • 7. Do you now have or have you ever had Joint Pain?
  • 8. Do you now have or have you ever had Knee pain or injury?
  • 9. Do you have or ever had Feet and/or Toes pain or injury?
  • 10. Do you have or everhad Ankle pain or injury?
  • 11. Have you ever had any type of orthopedic injury?
  • 12. Have you ever had any type of fracture?
  • 13. Do you now have or have you ever had Elbow pain or injury?
  • 14. Have you ever had Hand/Fingers and/or Wrist pain or injury?
  • 15. Do you now have or have you ever had Arthritis?
  • 16. Have you ever had joint dislocations or surgeries?
  • 17. Do you now have or have you ever had Plantar Fasciitis?
  • 18. Do you now have or have you ever had Ganglion cyst?
  • 19. Do you now have or have you ever had Fibromyalgia?
  • 21. Have you ever received chiropractic treatment?
  • 20. Have you ever received physiotherapy?

  • Dental

  • 1. Do you have or had teeth decay?
  • 2. Do you have or had gingivitis?
  • 3. Do you have implants or fake teeth?
  • 4. Do you have or had teeth impacted?

  • Vascular

  • 1. Do you have or had varicose veins?
  • 2. Do you have or had poor circulation?
  • 3. Do you have or had Gout?
  • 4. Do you have or had Atherosclerosis?
  • 5. Do you have or had Peripheral Artery Disease?
  • 6. Do you have or had aneurysm(s)?
  • 7. Do you have or had deep vein thrombosis (DVT)?

  • Miscellaneous/General Questions

  • 1. Have you had an Accident or Illness in the last 10 years?
  • 2. Have you ever been hospitalized?
  • 3. Have you ever received a blood transfusion?
  • 4. Have you had an operation or surgery?
  • 5. Are you taking any type of medication (incl. vitamins)?
  • 6. Are you undergoing any type of treatment?
  • 7. Do you have any type of implants, including dental?
  • 8. Are you undergoing or need dental treatment?
  • 9. Do you drink alcoholic beverages? If yes, how much?
  • 10. Do you Smoke? If yes, then how much per day?
  • 11. Have you ever had an MRI and/or CTScan?
  • 12. Have you ever had any type of cosmetic surgery?
  • 13. Are you now getting dental or vision treatment?
  • 14. Have you participated or are you in a weight lost program?
  • 15. Have you taken or are you taking any weight loss medication?
  • 16. Have you had Gastric Surgery?
  • 17. Are you now or have been on a nutritional plans?
  • 18. Do you have, or have you ever had an Eating Disorder?
  • 19. Have you or are you currently undergoing hormone therapy?
  • 20. Have you or are you currently in Transgender therapy?
  • 21. Do you drink energy beverages? If yes, how often per day?

  • Allergies

  • 1. Do you have or had food allergies?
  • 2. Do you have or had anaphylaxis allergies?
  • 3. Do you have or had environmental allergies?
  • 4. Do you have or had seasonal allergies?
  • 5. Do you have or had chemical allergies?
  • 6. Do you have or had drug/medicine allergies?
  • 7. Do you have or had any other type of allergy?

  • Rheumatology

  • 1. Do you have or had lupus?
  • 2. Do you have or had sarcoid disease?
  • 3. Do you have or had rheumatoid arthritis?
  • 4. Do you have or had carpal tunnel syndrome?
  • 5. Do you have or had fibromyalgia?
  • 6. Do you have or had inflammatory myopathies?
  • 7. Do you have or had osteoarthritis?
  • 8. Do you have or had osteoporosis?
  • 9. Do you have or had tendinitis or bursitis?

  • Gynecology

  • 1. Are you now or do you think you are pregnant?
  • 2. Do you have or had gynecological problems?
  • 3. Do you have or had endometriosis?
  • Do you have any chronic diseases?
  • Diabetes Type 1 - Stable Condition?
  • Diabetes Type 1 - Restrictions?
  • Diabetes Type 2 - Stable Condition?
  • Diabetes Type 2 - Restrictions?
  • Hypertension - Stable Condition?
  • Hypertension - Restrictions?
  • Cardiovascular Disease - Stable Condition?
  • Cardiovascular Disease - Restrictions?
  • Chronic Kidney Disease - Stable Condition?
  • Chronic Kidney Disease - Restrictions?
  • Autoimmune Disease - Stable Condition?
  • Autoimmune Disease - Restrictions?
  • HIV - Stable Condition?
  • HIV - Restrictions?
  • Osteoarthritis (OA) - Stable Condition?
  • Osteoarthritis (OA) - Restrictions?
  • Asthma - Stable Condition?
  • Asthma - Restrictions?
  • Hypercholesterolaemia - Stable Condition?
  • Hypercholesterolaemia - Restrictions?
  • Hypertriglyceridemia - Stable Condition?
  • Hypertriglyceridemia - Restrictions?
  • Depression - Stable Condition?
  • Depression - Restrictions?
  • Anxiety - Stable Condition?
  • Anxiety - Restrictions?
  • Back Pain - Stable Condition?
  • Back Pain - Restrictions?
  • Scoliosis - Stable Condition?
  • Scoliosis - Restrictions?
  • Migraine Headache - Stable Condition?
  • Migraine Headache - Restrictions?
  • Otitis - Stable Condition?
  • Otitis - Restrictions?
  • Arthritis - Stable Condition?
  • Arthritis - Restrictions?
  • Varicose Veins - Stable Condition?
  • Varicose Veins - Restrictions?
  • Carpal Tunnel - Stable Condition?
  • Carpal Tunnel - Restrictions?
  • Suicidal Idealogy - Stable Condition?
  • Suicidal Idealogy - Restrictions?
  • Self Harm - Stable Condition?
  • Self Harm - Restrictions?
  • Bi-Polar - Stable Condition?
  • Bi-Polar - Restrictions?
  • Schizophrenia - Stable Condition?
  • Schizophrenia - Restrictions?
  • Panic Disorder - Stable Condition?
  • Panic Disorder - Restrictions?
  • Are there are other Chronic diseases not listed above?
  • Chronic Disease 1 - Stable Condition?
  • Chronic Disease 1 - Restrictions?
  • Chronic Disease 2 - Stable Condition?
  • Chronic Disease 2 - Restrictions?

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - VIRGIN CRUISE LINE PEME FORM

    Declarations
  • Declarations

  • ROYAL CARIBBEAN GROUP PEME

    FORM

  • Hello,

    Before you go ahead with filling this form, you must have filled your FORM A on RiskConnect.

    FORM A: https://riskonnectrcl.my.site.com/EHR/s/peme

  • Are you a Perfect Destination employee (CocoCay, Labadee, and Perfect day Mexico).?*
  • Perfect Destination and Regular Crews have different FORM As. Please confirm you have filled the right Form A for your category?*
  • When did you fill Form A?*
     - -
  • Please give the reason why you have not filled your FORM A.*

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - CRUISE LINES PEME FORM

    Letter from GP / Specialists

  • If you have any current or historic medical problems, please try to get a recent letter from your GP or specilaist stating your current state of health and possibly giving you the all clear.

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  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - CRUISE LINES PEME FORM

    Your Vaccination History
  • Measles, Mumps, Rubella - Date Recieved
     - -
  • Tetanus - Date Recieved
     - -
  • Yellow Fever - Date Recieved
     - -
  • Hepatitis B - Date Recieved
     - -
  • Hepatitis A - Date Recieved
     - -
  • Meningitis - Date Recieved
     - -
  • Polio - Date Recieved
     - -
  • Varicella - Date Recieved
     - -
  • Influenza - Date Recieved
     - -

  • UPLOAD VACCINATINO HISTORY

    Please upload your full vaccination history here.

    You can get this as a print out from your NHS GP.

    If you do not have your full history, please ensure you upload your MMR at least.

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  • PROOF OF MMR

    If you do not have any evidence of MMR vaccination, you will either need a blood test (MMR Antibody Test: £205) to check that you are immune or you get vaccinated with one dose (£90 per dose).

     

    Pleae let us know what you would like to do.

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

  • YEHS - CRUISE LINES PEME FORM

    END OF FORM
  • Fit Questions

  • If you require further guidance, please call +44 (0)20 4617 6186 or email us on yehs@yourexcellenthealth.org

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