Notum

Seafarer's, inland waterway transport specialist's and motor pleasure craft navigator's health declaration (Laivavedžio garbės deklaracija)

Save time during your visit — you can submit the questionnaire in advance.

Your details

Personal details

Date of birth
Personal identification number
Sex
Permanent place of residence
Position
Professional group by type of work

Questions

Please answer the questions below by selecting the option that applies to you.

1. Have you previously had a medical examination for work at sea?
2. Have you ever been found unfit for work at sea and (or) had restrictions placed on your work at sea?
3. Have you been treated in hospital in the last two years?
4. In the last two years, have you been on continuous sick leave for more than 30 days?
5. Have you had lung diseases (tuberculosis, bronchial asthma)?
6. Have you had heart and cardiovascular diseases?
7. Have you had diseases of the ear?
8. Have you had diseases of the eye?
9. Have you had epilepsy?
10. Do you have diabetes?
11. Have you had severe allergic reactions / eczema / skin diseases?
12. Have you had mental disorders?
13. Have you had problems with alcohol or drug dependence?
14. Have you had any back pain problems (injury, rheumatism)?
15. Have you had a serious injury while working at sea?
16. Have you had digestive problems that required treatment?
17. Do you take any medicines regularly?
18. Do you wear glasses or contact lenses?
19. Do you find it difficult to find your way in twilight?
20. Can you tell colours apart?
21. Have you been assessed with a reduced capacity for work?
22. Additional question
Seafarer's, inland waterway transport specialist's and motor pleasure craft navigator's health declaration (Laivavedžio garbės deklaracija) — Notum