Please give a short history for any of the boxes you checked: ________________________________________________________
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I have read the lists above and marked all that apply. Signature:
Do you have any allergies? Y N
List allergies: ________________________________________________
Do you smoke? Y N If yes, # of cigarettes a day: ______________
Do you drink alcohol? Y N # of drinks a day: ______ week: ______
Have you ever been in the hospital? Y N
If yes: why & when? __________________________________________
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What operations have you had and when?
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What medications do you take on a routine basis?
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Will you need these medications while on board? Y N
For Females Only:
Date of last Pap? __________ Mammogram? _________
Do you have problems with your menstrual cycle? Y N
Date of your last period? ___________________
Are you on birth control? Y N
Circle type used: IUD / Pill / Injections / Other ________
Are you currently pregnant? Y N
Have you ever been refused a job or military service due to a medical condition, illness or injury? Y N
Have you ever been discharged from a job or military due to a medical condition, illness or injury? Y N
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? __________________________
Have you worked for Carnival Cruise Lines in the past? Y N
When? __________________________________________________________________________________________________________
Have you worked for any other cruise line before? Y N
Name of cruise line and dates of employment? ________________________________________________________________________
Please provide us with a description of any medical problems you have had in the past that were not addressed on these pages below:
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Proof of MMR Vaccination must be attached to the physical and carried by the crewmember
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The answers on my Employee Physical History forms including all representations concerning my prior medical history are true
and correct to the best of my knowledge and belief. I understand that Carnival Cruise Lines will rely on these medical forms in
determining whether I am eligible for employment. I also 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 any medical information concerning my past, present, or future medical condition by any practitioner or
hospital to Carnival Cruise Lines and its accredited representatives.
Please document and comment on all abnormal test results and physical findings in the space provided below.
A copy of all the applicant’s lab results must accompany these completed medical forms. Please document on general appearance and
mental attitude as needed. Please print clearly.
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Last date of menstrual period: ____________________ If it has been greater than 28 days since the last menstrual period please do
pregnancy test and attach result. If urine pregnancy dipstick test performed in the office please circle result: positive / negative.
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Proof of MMR Vaccination must be attached to the physical and carried by the crewmember
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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.
Rev 01/2007 Applicant/Crewmember Signature_____________________
