Last Name: First Name: Work Status:

Nationality: [ ] New Hire

Date of Birth ( Day/Month/Year): Gender [ ] Re Hire
Passport or Crew Identification #: [ ] Male [ ] Female [ ] Returning
Position on board:
MEDICAL CERTIFICATE FOR SERVICE AT SEA
On the basis of the examinee's personal declaration, my clinical examination and diagnostic test results
recorded on the medical examination form, I declare the examinee:
Fit for Duty [ ] Unfit for Duty
[ ] Without Restriction
[ ] With Restriction

List Restrictions:

Does the seafarer have any medical condition likely to be aggravated by service at sea or might
endanger others onboard? [ ] Yes [ ] No
If YES, must explain:

Hearing meets standards: [ ] Yes [ ] No Deck & engine seafarers only:

Visual acuity meets standards: [ ] Yes [ ] No Normal color vision exam within the past
Proof of MMR Immunity on file [ ] Yes [ ] No 6 years: [ ] Yes [ ] No

Official stamp of either medical facility or medical examiner:

Seafarer's
Photo
Print name of Medical Examiner:_________________________________
Signature of Medical Examiner:__________________________________
Name of medical Facility:____________________________________
Location of medical Facility: __________________________________
Date of the exam: _____/_____/____
Day/Month/Year

Expiration Date:_____/_____/_____ (expires two years from the examination date)

Day/Month/Year

This document is in accordance with STCW regulation I/9 or ILO-73 ( 1946 ) or ILO-147 ( 1976 ) or ILO/IMO
or ILO Maritime Labour Convention 2006 ( MLC-2006 ) " Guidance on the Medical Examination for Seafarers ".

Rev 02 / 2013
 New Hire □
Employee History Returning □
To be completed by all new hires and returning crewmembers. Rehire □
Name: Date of Birth: Nationality:

Position: Crew # Department: _ Date of Hire:

Address: _ Home Telephone #:

HAVE YOU HAD, BEEN TREATED FOR, AND/OR NEED FOLLOW-UP FOR ANY OF THE PROBLEMS LISTED BELOW.
PLEASE MARK YES OR NO .

Yes No Yes No Yes No

  Eye disease or injury   Diabetes   Anxiety / Depression
  Glasses / contacts   Digestive disorder/colon disease   Attempted Suicide
  Severe headaches   Stomach Ulcers   Sleeping disorders
  Dizziness / fainting spells   Acid reflux   Sleep walking
  Seizures / Epilepsy   Chronic vomiting / diarrhea   Eating disorders
  Recurrent ear Infections   Gallbladder or liver disease   Alcohol or Drug dependency
  Hearing loss   Malaria/Dengue/Rheumatic fever   Benign tumors
  Frequent nose bleeds   Arthritis/joint deformity   Breast lumps / masses
  Deviated septum   Recurrent joint dislocations   Cancer Type:
  Chronic sinus infections   Fractures (broken bones)   Anemia / blood disorders
  Untreated dental cavities   Amputations / prosthetics   Hepatitis: B / C
  Asthma   Injury or surgery to extremity or joint   Kidney stones
  Chronic Bronchitis   Injury or surgery to back   Recurrent urinary infections
  Emphysema   Chronic back pain   Genital herpes
  Tuberculosis   Scoliosis   HIV
  Skin problems / rashes   Chronic muscular pain   Syphilis / Gonorrhea
  Thyroid disease   Chronic pain (knee, shoulder, elbow)   Venereal warts
  High blood pressure   Varicose Veins/Surgery   Hemorrhoids
  Heart problems   Hernias of any kind   Blood in urine or stools
  Heart attack or stroke   Psychiatric disorders   Any other surgery (Operations)

Please give details of YES answers:

I have read the lists above and answered truthfully. Signature:

Do you have any allergies? Y N For Males Only:

List Allergies: Prostate Problems: Y N
Do you smoke? Y N If yes, # of cigarettes per day: Testicular lumps/problems: Y N
Do you drink alcohol? Y N # of drinks per day: For Females Only:
Have you ever been hospitalized? Y N Date of last Pap smear? Mammogram?
If yes: why & when? Do you have menstrual irregularities? Y N
Heavy bleeding/severe pain that limits your activities: Y N
What medications do you take on a routine basis? Date of your last period:
Are you currently pregnant? Y N

Will you need these medications while onboard? Y N Applicant/Crewmember Signature

Date: _________________________

Rev 03/2013
Page 1 of 4
 Employee Physical Examination

To be completed by all new hires and returning

crewmembers.

Name: Crew #

1. Have you ever been refused a job or military service due to a medical condition, illness or injury? Y N
2. Have you ever been discharged from a job or military due to a medical condition, illness or injury? Y N
3. Have you ever been medically disembarked from any ship? Y N
4. Have you ever been given any money for a job related illness or injury? Y N
What was the injury or illness? When did it happen?

Please provide details for positive answers:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________________

The answers on my Employee Physical History forms are true and correct to the best of my knowledge and belief.
I understand that falsification of these records is grounds for termination and may constitute grounds for denial of
maintenance and cure benefits in the event that I become ill or injured.
I authorize release of all medical information concerning my past, present, or future medical condition by any
practitioner or hospital to Carnival Cruise Lines and its accredited representatives.

Applicant/Crewmember Signature Date

Rev 03/2013 Page 2 of 4

 Employee Physical Examination
To be completed by the examining physician.

Name: Crew #

Vital signs
Blood pressure:
Systolic: __________
Weight: __________
Diastolic: __________
Height: __________
Body Mass Index = __________
Pulse rate: _______ / minute

Rhythm: Regular Irregular

Normal Abnormal Normal Abnormal

General Appearance   Abdomen and Viscera  

Head, Face, Neck & Scalp   Anus  
Nose   Skin  
Sinuses   External genitalia  
Mouth, Teeth & Throat   Locomotion / Agility  
Ears / Ear Drum   Spine (Upper/Mid/Lower)  
Eyes / Pupils / Ocular Motility   Other Musculoskeletal  
Ophthalmoscopy   Identifying Body Marks, Scars, Tattoos  
Lungs / Chest   Lymph nodes  
Breast Exam   Neurologic  
Heart   Psychiatric  
Vascular/Peripheral Pulses   Varicose Veins Y N  

VISION
1. Visual Acuity 2. PHERIPHERAL VISION
Use of Glasses or Contact Lenses None Glasses Contact Lenses
Unaided Aided Normal Defective
Right Eye Left Eye Right Eye
Distant Left Eye
Near 3. COLOUR VISION: Not Tested Normal Defective

HEARING
1.) Whisper Test
Normal Abnormal
Right Ear
Left Ear

DOCTOR’S COMMENTS: on all positive responses in the questionnaire and abnormal clinical findings.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
___________________________________________________________________________________________________
Date of exam: Doctor Initials:

Page 3 of 4
Rev 03/2013
 Employee Physical Examination

To be completed by the examining physician

Name: Crew #

LABORATORY TEST ( Attach ALL results )

Normal Abnormal Positive Negative

EKG (For Females 45 + & Males 40+)   Stool for Hemoccult (For All Crew 50+ )  
PSA (For All Crew 50+ )   Stool Culture for Salmonella & Shigella and Stool for Ova/ Positive Negative
Parasites
(Food and beverage & Youth Crew only)  

Required for ALL CREW

Normal Abnormal Normal Abnormal
Chest X-ray   SGOT/AST and SGPT /ALT  
HbA1C   Bilirubin  
CBC   Positive Negative
BUN (Blood Urea Nitrogen)   Pregnancy Test (For Females)  
Creatinine   Hepatitis C and Hepatitis B  
VDRL or RPR   HIV  
Drug Test  
Doctor comments on ALL abnormal or positive tests

MMR Proof of Vaccination or Immunity must be attached and is Mandatory for ALL CREW

I certify that I have examined the above named applicant according to the medical standards provided by Carnival Cruise Lines and
can attest this applicant has completed all required tests and with a full physical examination, I have identified no reportable
deficiencies, other than those listed above.

Printed name of examining physician: Signature:

Address of examining physician:

Telephone: Date of exam:

Physician or facility Stamp:

Rev 03/2013 Page 4 of 4