Medical Questionnaire | Baranof Courageous

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Health Assessment

"*" indicates required fields

Name*

First Last

Today's Date*

MM slash DD slash YYYY

Phone*

Email*

Date of Birth*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Primary Care Physician

Primary Care Physician Location

City State

In case of emergency, notify:*

First Last

Relationship

Phone

What is your usual occupation?

Position offered

Are you physically fit?*

Yes

No

Height*

Weight*

Date of last dental exam*

MM slash DD slash YYYY

Date of last tetanus shot*

MM slash DD slash YYYY

Have you seen a doctor in the past 5 years?*

Yes

No

If so, when and reason for visit(s)

Are you currently receiving medical treatment?*

Yes

No

If Yes, describe

Are you currently taking medication of any kind?*

Yes

No

If Yes, describe

Are you allergic to any medications?*

Yes

No

If Yes, describe

Have you been refused employment or had to leave a job, either temporarily or permanently, because of

Sensitivity to chemicals, dust, sunlight, etc.

Inability to perform certain motions

Inability to assume certain physical positions

Other medical reasons

No

If Other, please provide detail*

Have you had or been advised to have any surgical procedures?*

Yes

No

If Yes, please provide detail*

Have you ever been treated at a hospital or hospitalized for any reason whatsoever?*

Yes

No

If Yes, please provide detail*

Do you have any physical discomfort when you work in dampness or cold?*

Yes

No

If Yes, please provide detail*

Has your work ever been restricted on account of your health?*

Yes

No

If Yes, please provide detail*

Do you have any condition requiring a special work assignment or limitation?*

Yes

No

If Yes, please provide detail*

Do you have any problem which would restrict or make more difficult repetitive lifting or any other heavy physical labor?*

Yes

No

If Yes, please provide detail*

Have you ever been a party in a lawsuit for a personal injury, industrial injury or made claim(s) for injury under maritime law?*

Yes

No

If Yes, please provide detail*

Have you ever been denied employment for medical reasons?*

Yes

No

If Yes, please provide detail*

Have you ever been rejected or discharged from military service for medical reasons?*

Yes

No

If Yes, please provide detail*

Have you ever been denied an insurance policy for medical reasons?*

Yes

No

If Yes, please provide detail*

Have you ever been exposed to toxic chemicals, vapors, fumes, mists, dusts, radiation or excessive noise?*

Yes

No

If Yes, please provide detail*

Treated for mental condition?*

Yes

No

If Yes, please provide detail*

Do you drink?*

Yes

No

If Yes, please provide detail*

Do you use recreational drugs?*

Yes

No

If Yes, please provide detail*

Do you smoke?*

Yes

No

If Yes, please provide detail*

Have you ever had, or do you currently have, any of the following:

Dizziness, vertigo, fainting spells, balance disorder*

Yes

No

Please explain:*

Seizures/epilepsy*

Yes

No

Please explain:*

Sinusitis, sinus problems*

Yes

No

Please explain:*

Disorder of eyes/ears/nose/throat*

Yes

No

Please explain:*

Ear disease, injury, surgery*

Yes

No

Please explain:*

Poor vision, corrective lenses for vision?*

Yes

No

Please explain:*

Allergies, hay fever, allergic reactions*

Yes

No

Please explain:*

Chronic cough, sore throat*

Yes

No

Please explain:*

Tuberculosis*

Yes

No

Please explain:*

Aneurysm or blockages*

Yes

No

Please explain:*

Collapsed lung/pneumothorax*

Yes

No

Please explain:*

Heart attack/myocardial infarction*

Yes

No

Please explain:*

Heart surgery/stent/angioplasty*

Yes

No

Please explain:*

Heart murmur, valve replacement*

Yes

No

Please explain:*

High or low blood pressure /hypertension*

Yes

No

Please explain:*

Rheumatic fever*

Yes

No

Please explain:*

Crohn's disease, ulcerative colitis or IBS*

Yes

No

Please explain:*

Intestinal surgery*

Yes

No

Please explain:*

Cramps*

Yes

No

Please explain:*

Kidney disease, transplant, cancer or dialysis*

Yes

No

Please explain:*

Kidney stone(s) or bladder problems*

Yes

No

Please explain:*

Hemophilia or polycythemia*

Yes

No

Please explain:*

Any form of cancer*

Yes

No

Please explain:*

Diabetes*

Yes

No

Please explain:*

Shooting pains*

Yes

No

Please explain:*

Carpal tunnel/wrist discomfort*

Yes

No

Please explain:*

Foot problem(s)*

Yes

No

Please explain:*

Skin disease, rash, burns, tumors or cysts*

Yes

No

Please explain:*

Back problems, complaint, or injury*

Yes

No

Please explain:*

Herniated or ruptured disc*

Yes

No

Please explain:*

Sciatica or nerve pain*

Yes

No

Please explain:*

Problems of upper or lower extremities*

Yes

No

Please explain:*

Lumps, pain, numbness or tingling in hands or wrists*

Yes

No

Please explain:*

Locking fingers*

Yes

No

Please explain:*

Arthritis, rheumatism or bursitis*

Yes

No

Please explain:*

Broken, dislocated bones/joints*

Yes

No

Please explain:*

Bone or joint surgery*

Yes

No

Please explain:*

Head injury or skull fracture*

Yes

No

Please explain:*

Stroke or TIA*

Yes

No

Please explain:*

Loss of memory or amnesia*

Yes

No

Please explain:*

Depression, schizophrenia, anxiety*

Yes

No

Please explain:*

Psychiatric disease, counseling or mental disorders*

Yes

No

Please explain:*

Rectal disease, hemorrhoids*

Yes

No

Please explain:*

HIV or AIDS*

Yes

No

Please explain:*

Motion/sea sickness*

Yes

No

Please explain:*

Frequent headaches. migraines*

Yes

No

Please explain:*

Thyroid disease*

Yes

No

Please explain:*

Hearing loss, hearing aid*

Yes

No

Please explain:*

Glaucoma*

Yes

No

Please explain:*

Asthma*

Yes

No

Please explain:*

Emphysema or COPD*

Yes

No

Please explain:*

Shortness of breath, breathing problem(s*

Yes

No

Please explain:*

Hernia problems/surgery*

Yes

No

Please explain:*

Pulmonary embolus or blood clots*

Yes

No

Please explain:*

Chest pain, pressure or angina*

Yes

No

Please explain:*

Congestive heart failure*

Yes

No

Please explain:*

Pacemaker or defibrillator*

Yes

No

Please explain:*

Irregular heartbeat, palpitations*

Yes

No

Please explain:*

Any other Heart problem(s), pain/pressure in chest*

Yes

No

Please explain:*

Frequent indigestion*

Yes

No

Please explain:*

Gastrointestinal bleeding or ulcers*

Yes

No

Please explain:*

Any other stomach, liver or intestinal trouble*

Yes

No

Please explain:*

Hepatitis, jaundice or other liver problems*

Yes

No

Please explain:*

Frequent, painful or difficult urination*

Yes

No

Please explain:*

Anemia*

Yes

No

Please explain:*

Any other disease or disorder of the blood*

Yes

No

Please explain:*

Lymphoma or Leukemia*

Yes

No

Please explain:*

Low blood sugar*

Yes

No

Please explain:*

Tingling/numbness in any part of body*

Yes

No

Please explain:*

Wear any form of brace/support*

Yes

No

Please explain:*

Bleeding disorders*

Yes

No

Please explain:*

Varicose veins or leg pains*

Yes

No

Please explain:*

Back surgery or injury*

Yes

No

Please explain:*

Pain or numbness in legs*

Yes

No

Please explain:*

Recurrent neck or back pain or problem(s)*

Yes

No

Please explain:*

Knee problem(s)*

Yes

No

Please explain:*

Swelling of legs, ankles, hands or wrists*

Yes

No

Please explain:*

Tendonitis*

Yes

No

Please explain:*

Discomfort, sprains of joints*

Yes

No

Please explain:*

Amputation or prosthesis*

Yes

No

Please explain:*

Neurofibromatosis*

Yes

No

Please explain:*

Brain tumor or disease/nerve disease*

Yes

No

Please explain:*

Nervous trouble of any sort*

Yes

No

Please explain:*

ADD, ADHD or bipolar*

Yes

No

Please explain:*

Attempted suicide*

Yes

No

Please explain:*

Gall bladder problems/surgery*

Yes

No

Please explain:*

Sexually transmitted disease (STD)*

Yes

No

Please explain:*

Sleep apnea, narcolepsy, other sleep disorders*

Yes

No

Please explain:*

Have you had any illness(es) or injuries other than those already listed?*

Yes

No

Please explain:*

Signature*

I certify that the facts and my answers on this questionnaire are true and complete to the best of my knowledge. I understand that any falsifications, misrepresentations or omissions will be cause for withdrawal of conditional job offer or immediate termination regardless of when or how discovered. The terms “misrepresentation” or “omission” include failure to complete this questionnaire form. It is the company policy that inadequately completing company documents may be grounds for denial of employment, withdrawal of a conditional job offer or immediate termination. Inadequate completion includes drawing a line through all “NO” responses since this indicates failure to appropriately consider the company’s request for information. Additionally, false or misleading answers may be a basis for denial of benefits under federal maritime law, denial of maintenance and/ or cure, or any otherwise applicable benefits. Providing thorough and accurate information is required.

Δ

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tel: (206) 545-9501
fax: (206) 545-9536

M/V Baranof & M/V Courageous
4502 14th Avenue NW
Seattle, Washington 98107-4618

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