POE Declaration of Health

Note: In the absence of a surgeon, the master should regard the following symtoms as ground for suspecting the existence of a disease of an infectious nature:

Fever, persisting for several days or accompanied by:

prostration  
decreased consciousness  
glandular swelling  
jaundice  
cough or shortness of breath  
unusual bleeding  
paralysis  
 

With or without fever:  

- any acute skin rash or eruption
- severe vomiting (other than sea sickness)  
- severe diarrhea  
- recurrent convulsions
 


 

sailing to Esbjerg, DK
Enter issue date
Please list ports of call from commencement of voyage or within past thirty days, whichever is shorter, stating dates og departure:
PortDate
Please list crew members, passengers or other persons who have joined ship/vessel since international voyage began or within past thirty days, whichever is shorter, including all ports/countries visited during this period:
No. of personsJoined DateJoined PortComments - Additional information

Health Questions

If yes, state particulars in attached form.
If yes, please state particulars.
If yes, please state particulars
If yes, please state particulars of medical treatment or advice provided in attached form.
If yes, please state particulars.
If yes, please specify type, place and date.
TypePlaceDate
I hereby declare that the particulars and answers to the quetions given in this Declaration of Health are true and correct to the best of my knowledge and belief.