《海航医疗诊断证明书.doc》由会员分享，可在线阅读，更多相关《海航医疗诊断证明书.doc（3页珍藏版）》请在金锄头文库上搜索。
1、海航医疗诊断证明书Hainan airlines (HU)MEDICAL INFORMATION SHEET (MEDIF)诊 断 证 明 书由主治医生填写1）This form is intended to provide CONFIDENTIAL informaiton to enable Hainan Airlines to assess the fitness of the passenger to travel,if the passenger is acceptable, this information will permit the issuance of the necess
2、ary directives designed to provide for the passengers welfare and comfort.此表中提供的保密信息，用于海南航空评估旅客是否适宜成行。如果旅客可以运输，我们会根据此表中服务需求进行安排和准备，为旅客提供安全和舒适的服务。2）The PHYSICIAN ATTENDING the incapcitated passenger is requested to ANSWER ALL QUESTIONS ,Enter a cross “”in the appropriate “yes”or “no”boxes, and/or giv
3、e precise concise answers.请病患/残疾旅客的主治医生按要求回答以下所有的问题，在相应的“是”或“否”的框中打“”，并且/或者给予精确简练的回答。3）COMPLETING OF THE FORM IN BLOCK LETTERS OR BY TYPEWRITER WILL BE APPRECIATED请用黑粗字体填写此表，或者用打印机打印，要求不留空白项。4）The form must be returned to Hainan Airlines booking office where passenger purchase the tickets.此表填写完成后必须交
4、还给海南售票部门。MEDA1PATIENTS NAME ,SEX,AGE患者姓名，性别，年龄MEDA2ATTENDING PHYSICIANS name and adress主治医生姓名，地址，ATTENDING PHYSICIANS telephone contact主治医生联系电话办公电话Business: 家庭电话Home:MEDA3MEDICAL DATA医疗信息DIAGNOSIS in details (including vital signs)诊断详细资料（包括重要症状）Day/month/year of first symptoms第一次症状发生的时间 日/月/年Date of
5、 opration手术日期：Date of diagnosis诊断日期：MEDA4-PROGNOSIS for the flight(s): 根据症状对疾病在飞行中的结果进行预测MEDA5-Contagious AND communicable disease? 是否有传染性疾病？ No否 Yes是 Specify详细说明: MEDA6-Would the physical and/or mental condition of the patient be likely to cause distress or discomfort to other passengers? 患者的身体和/或精
6、神状况是否会对其他旅客造成危害或引起其他旅客不安或不舒适？ No 否 Yes是 Specify详细说明: MEDA7-Can patient use normal aircraft seat with seatback placed in the UPRIGHT position when so required? 当飞机因安全需要调直座椅靠背时，患者是否可以使用普通客舱座椅？ Yes 是 No否 MEDA8-Can patient take care of his own needs on board UNASSISTED (including meals, visit to toilet,
7、 etc.)?在飞机上，患者是否可以照顾自己（包括进餐，去洗手间等）？ Yes是 No否 If not ,type of help needed:如旅客不能照顾自己，请填写协助需求： MEDA9-If to be ESCORTED, is the arrangement Satisfactory to you? 如果旅客需要进行陪护，您认为陪护人员的安排是否合适？ Yes是 No否 If not ,type of escort proposed by YOU：如果您认为不妥，请说明您的陪护人员安排建议： MEDA10-Does patient need OXYGEN equipment in
8、flight? 患者在机上是否需要氧气设备？ No否 Yes是 （if yes, state rate of flow 如果需要请说明流量） Liters per minute升/分钟 ；continuous是否持续? No否 Yes是 MEDA11-Does patient need any MEDICATION（*NOTICE）, other than self-administered, and/or the use of special apparatus such as respirator, incubator, etc.?除了患者自己准备的药物，患者是否还需要一些药物，和/或是否
9、需要使用特殊设备，比如呼吸器、恒温箱等？(a) on the GROUND while at the airport(s) 在机场候机楼地面：No否 Yes是 Specify详细说明: (b) on the board of the AIRCRAFT 在飞机上客舱内：No否 Yes是 Specify详细说明: MEDA12MEDA13-Does patient need HOSPITALISATION? 以下两种情况，患者是否需要住院治疗？ (if yes, indicate arrangements made or, if none were made, indicate“NO ACTION
10、 TAKEN”) （如果“是”，请简要说明已进行的住院安排情况；如果“否”，请注明“没有进行安排”）(a) during long layover or night stop at CONNECTING POINTS en route 在衔接站长时间停场或过夜停留：No否 Yes是 Action安排情况: (b) upon arrival at DESTINATION：到达终点站：No否 Yes是 Action 安排情况: MEDA14MEDA15-Other remarks or information in the interest of your patients smooth and
11、comfortable transportation: 为了使旅客能够更加舒适、顺利进行航空运输，请提供其他相关信息：None无 Specify if any其他的详细说明： MEDA16-Other arrangements made by the attending physician:主治医生的其他安排： NOTE:Cabin attendants are NOT authorized to give special assistance (e.g. lifting) to particular passengers, to the detriment of their service
12、to other passengers. Additionally, they are trained only in FIRST AID and are NOT PERMITTED to administer any injection, or to give medication.备注：不允许客舱乘务员向特殊旅客提供某项特别的帮助（如抬或架起）,而对其他旅客造成损害。此外，客舱乘务员仅仅只进行了急救培训，不允许进行注射或提供药物救治。IMPORTANT:FEES, IF ANY, RELEVANT TO THE PROVISION OF THE ABOVE INFORMATION AND
13、FOR CARRIER-PROVIDED SPECIAL EQUIPEMNT ARE TO BE PAID BY THE PASSENGER CONCERNED.重要说明：关于以上所提到的供应品和承运人提供的特殊设备，这些费用由患者支付。Date日期：Place地点：Attending Physicians Signature主治医生签名：PASSENGERS DECLARATION旅客声明“I HEREBY AUTHORIZE (Name of nominated physician) to provide the airlines with the informaiton required by those airlinesmedical departments for purpose of determining my fitness for carriage by air and in conside
