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1、诊 断 证 明 书Certificate of Diagnosis1旅客姓名Name of Passenger： 2年龄Age： 3性别Sex： 4地址及联系方式Add. and contact： 5航程Routing：航班号Flight No. HU 日期Date 月Month 日Day 自From 至to 联程Via：航班号Flight No. 日期Date 月Month 日Day 自From 至to 6诊断结果Result of diagnosis： 7症状、程序、预后（如系孕妇需注明预产期）Symptom, process, prognosis (indicate expected d
2、ate of childbirth, if pregnant woman)： 注（1）上述第6、7两项内容填写，需简单、明确。（2）下述表格中提供的内容，供机上服务人员在飞行途中为病伤旅客提供必要的服务时作为参考。Note (1) The above described 6 and 7 items shall be filled shortly and clearly. (2) The content described in the form under is for reference to cabin crew who offer necessary service to sick or
3、 injured passengers during flight.程度Degree症状Symptom无Normal轻度Mild中等Moderate严重Severe备注Remark贫血Anemia呼吸困难Dyspnea疼痛Pain血压Blood Pressure8附注：（如有膀胱、直肠障碍或者在飞行中需要特殊餐食及药物医疗处理情况等，请予以列明）PS: (If suffering from bladder and recta, or needing special food and medical treatment on the flight, please list it clear) 9
4、需要何种坐姿（将下列适用的项目用 圈起）Which kind of seating position is needed (Enclose the following applicable items with )：乘坐姿态Seating Position1使用机上一般座椅Taking common seat 2使用机上担架设备Using supporting equipment陪伴人员Attendance医生 Doctor 护士 Nurse 其他人员（具体列明）Others (list in details) 不需要 No need上下飞机时Deplane or enplane轮椅Wheel
5、chair要 Need 不要 No Need担架Stretcher要 Need 不要 No Need救护车Ambulance要 Need 不要 No Need已参阅下面的资料，我院诊断认为：该旅客的健康条件在医学上能够适应上述航空旅行的要求，无传染疾病，也不致造成对其他旅客的不良影响。After referring the under documents, we make a diagnosis: the health condition of this passenger meets the requirements of air travel, he/she hasnt communica
6、ble disease, and doesnt influence other passengers.医师（签字）Physician (signature)： 电话Tel： 医疗单位（盖章）Medical Unit(seal) 日期（年月日）Date(Y./M/D)： 参考资料（下述内容仅供医生在判断病人是否适于航空旅行时的参考）References (The following contents are only for physicians reference on the fact whether a patient is suitable for air travel or not)一
7、、机上条件I. Conditions on board：1飞机具有密封，增压客舱。舱内气压相当于2300公尺（7000英尺）高度的大气压力，因此能引起体腔内气体的膨胀，同时也造成轻度的缺氧状态。The airplanes cabin is sealed and pressurized. Cabin pressure is equivalent to the atmospheric conditions at 2300 meter (7000 ft), which cause expansion of body cavities and mild anaerobic conditions.2飞机
8、在飞行中会有较大的颠簸及震动。Great jolt and vibration may be occurred while flying.3机上服务人员只受过一般的急救训练，但不允许为病人注射。同时，在飞行途中机上服务人员需担负整个飞机上的服务工作，无暇更多地特别照看病人。The cabin crew are only trained for common first aid, and not allowed for patient injection. And that, the cabin crew should be responsible for service during flig
9、ht, so they have no time to especially attend patients more.4机舱内的活动范围和舒适程度受到机舱技术设备的一定限制。Activities space and comfortable will be limited by technique and equipment in cabin.二、处于下述状况的病人，一般不适于航空旅行II. The people, who is in the following conditions, isnt suitable for air travel：1处于极严重或者危急状态的心脏病患者。如严重的心力
10、衰竭，出现紫绀症状或者心肌梗塞者（在旅行前六周之内增发生过梗塞者）。The cardiopath is of severe case or in critical status, e.g. severe heart failure, cyanosis, or myocardial infarction (The case of myocardial infarction occurred within six weeks before traveling)2出生不满14天的婴儿。Infant under 14-day age3孕妇。怀孕期限超过36周者（怀孕期在36周以内超过32周的孕妇乘机，
11、需具有医生在72小时之内签署的诊断证明书）。The pregnant woman whose pregnancy exceeding 36 weeks. (If the pregnant woman, whose pregnancy is more than 32 weeks but not exceeding 36 weeks, wants to take airplane, it requires her to offer a physicians signed certificate of diagnosis dated within 72-hour before departure.)
12、4血色素量在50%（Hb8g.dl）以下的贫血病人。The patient suffering from anemia with hematochrome level below 50% (Hb 8.0 g.dL)5严重的中耳炎，伴随有耳咽管堵塞症的患者。The patient suffering from severe tympanitis with obstruction of eustachian tubes6近期患自发性气胸的病人或者近期做过气脑造影的神经系统病症的患者。The patient suffering from spontaneous pneumothorax recent
13、ly or received pneumoencephalography (PEG) of the nervous system.7大纵隔瘤，特大疝肿及肠梗阴的病人；头部损伤，颅内压增高及颅骨骨折者；下颌骨骨折最近使用金属线连接者。The patient suffering from mediastinum tumour, serious hernia and intestinal obstruction; head injury, intracranial hypertension and fracture of skull; and fracture of mandible joined with wire recently.8酒精或者其他毒品中毒者；患有精神病，易于伤人或者自伤行为者。Alcoholism o
