Scribd
Upload
7 views3 pages

Medical Questionnaire PS Offshore Vessels

The document contains personal and medical information for Andi Umar Makmur, including his address, date of birth, and contact details. It includes a medical questionnaire assessing various health conditions, medications, and lifestyle habits, with most responses indicating no significant health issues. The applicant certifies the accuracy of the information provided and acknowledges the voluntary nature of the questionnaire.

Uploaded by

andiumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
7 views3 pages

Medical Questionnaire PS Offshore Vessels

The document contains personal and medical information for Andi Umar Makmur, including his address, date of birth, and contact details. It includes a medical questionnaire assessing various health conditions, medications, and lifestyle habits, with most responses indicating no significant health issues. The applicant certifies the accuracy of the information provided and acknowledges the voluntary nature of the questionnaire.

Uploaded by

andiumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Full Name: First Name Andi Umar

Last Name Makmur

Address: Street Address 1 Jalan Tinumbu, no 86, Kelurahan Bunga Ejaya, Kecamatan
Bontoala, Kota Makassar, Indonesia
Street Address 2
City Makassar
Country Indonesia
Post Code 90145

Date of Birth: Day Month Year


20 08 1993

Gender: MALE ✘ FEMALE

E-Mail: [email protected]

Phone Area Code +62


Number: Phone Number 82345229090

1. Check the conditions that apply to you below:

Asthma

Diabetes

Hypertension

Cardiac Disease

Cancer

Epilepsy

2. Has your doctor ever said that your blood pressure was too high or too low?
Yes ✘ No

3. Has your doctor ever told you that your cholesterol was too high?
Yes ✘ No

4. Do you have any injuries or orthopaedic problems (Back, Knees, etc..)?


Yes ✘ No

5. Do you have stiff or swollen joints?


Yes ✘ No

6. Do you have any tension or soreness in any area?


Yes ✘ No

7. Are you taking any prescribed medications or dietary supplementation?


Yes ✘ No

Please provide more details:

8. Does any medical condition exist or is there any other known disability, abnormality or recurrent
illness/chronic or injury or is there any known or foreseeable need to consult a medical practitioner?
Yes ✘ No

9. Do you have any impaired vision, Glaucoma, Retinopathy or other eye condition or are you wearing
corrective lenses (glasses, contact lenses or implants)?
Yes ✘ No

10. Do you have any medication allergies?


Yes
✘ No

Not Sure

Please provide more details:

11. Do you have problems sleeping?


Yes ✘ No

12. Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise or
activity or anything specific?

Yes ✘ No

13. Do you have any other medical condition, injury or anything we should be aware of?
Yes
✘ No

Not Sure

Please provide more details:

14. Do you use, or do you have any history of using tobacco?


Yes ✘ No

15. Do you use, or do you have any history of using illegal drugs?
Yes ✘ No

16. How often do you consume alcohol?


Daily
Weekly
Monthly
Occasionally
✘ Never

By my signature below, I certify the information I provided on and in connection with this form is true
and correct to the best of my knowledge. I also understand that any false statements or deliberate
omissions on this form may subject me to legal actions for fraudulent misrepresentation.

Applicant Full Name: ANDI UMAR MAKMUR

Applicant signature: AUM

Date: 27/02/2024

*This Medical questionnaire is however not compulsory, it is purely and solely for usage in cases if you
fall sick during the mission, should you not wish to fill in the details, please sign only below section:

Applicant Full Name: ANDI UMAR MAKMUR

Applicant signature: AUM

Date: 27/02/2024

You might also like