Pre - Join medical Questionnaire

This questionnaire is compulsory for each Smit Lamnalco employees allocated to any asset, the questionnaire must be completed prior
mobilization and send to the designated crew coordinator for further process.

First Name: INDARA

Middle Name:
Last Name: DEWA
Date of Birth: May,18th 1983
Marital status: Married
Number of children: 3 (three)
Gender: Male
Position: Master
Allocated Unit: SL KITE
Location (Departing to): Iraq

State down the last 5 countries you visited the last 3 years:
Bangladesh

Medical History:

Height (cms): 170 cm

Weight (kgs): 62 kg
Blood Type: O
Identification Mark on Body: (If any)
Colour of Eyes: black
Medical history:
Are there any organs removed? no
Have you suffered from jaundice (hepatitis) ? no
Are you an immuno-compromised patient ? no
Have you had a recent chemotherapy or radiation therapy ? no
Are you allergic to certain medication (i.e. antibiotics) ? no
Have you ever experienced problems after vaccination (i.e. fainting) ? never
Have you ever experienced complaints when using malaria tablets ? never
Do you smoke ? How much a day ? When did you stop smoking ? yes,+/- 6 sticks/day
Do you drink alcohol ? How much a day ? no
Do you wear glasses or contact lenses ? no
Are there any hereditary diseases in your family ? Is so specify no
Do you suffer from any blood clotting disorder ? no

General health >> Have you ever experienced any of the following ailments / condition ?

Diabetes no
Cancer no
Thyroid disorder no
Thrombosis or embolism no
Stroke no
(Epileptic) Seizures no
Psychiatric problems (i.e. burn out or depression) no
Dreams, nightmares no
Headache yes (very seldom)
Dizziness no
Reduced or blurry vision no
 Hearing impairment no
Coughing no
Shortness of breath no
Sighing pain no
Flu no
Throat ache no
Ear pain no
Bronchitis, asthma no
High blood pressure no
Heart disorders no
Chest pain no

General health >> Have you ever experienced any of the following complaints ?

Palpitations no
Vasculair prosthesis, pacemaker no
Swollen ankles no
Gastric pain no
Gastric acid yes (very seldom)
Nausea no
Stomach, cramps no
nocturia no
Constipation no
Diarrhea no
Bloody stools no
Liver problems no
Kidney problems no
Micturition problems (i.e. weak urine stream, incontinence) no
Sexually Transmitted Disease no
Hernia no
Varicose, hemorrhoids no
Pain in extremities (arms, legs), joints no
Myalgia (muscle ache) no
Back pain no
Sore feet no
Skin diseases, eczema, psoriasis no
Skin rash no
Itch no
Mouth ulcers no
Wounds, ulcers no
Frequent infections no
Insect bite, animal bite, sun burns yes,by mosquito
Cold or heat intolerance no

General health >> General (Social) History:

Do you exercise regularly ? If so, what sport and how often ? running at least 3 times a week
Have you been swimming in any lakes or rivers in the tropics ? no
Have you experienced conflicts with your family ? no
Have you experienced any conflicts at work ? no
Are you able to fulfill your duties at work ? yes
Do you have other complaints concerning your health which you haven't seen in
no
previous questions ?
How would you consider your health at the moment ? fit to work
Do you suffer from night blindness ? no
Are you colorblind? no
Have you had an eye laser treatment ? no
Have you been using drugs in the last 5 years ? no
When was your latest dental visit ? 3 month ago
Do you suffer from fear of heights / spaces / claustrophobia? no
Do you suffer from insomnia, sleep walking, bedwetting ? no
Do you suffer from seasickness? no

I acknowledge and confirm that I have completed this questionnaire truth full and ate and Place: Indonesia, Sept,14th 202
honestly and agree that any missing or wrong information can lead to termination of
my seafarers employment contract. Printed Name
and Signature: INDARA DEWA