海航醫(yī)療診斷證明書

1、海航醫(yī)療診斷證明書Hainan airlines (HU)MEDICAL INFORMATION SHEET (MEDIF)診 斷 證 明 書由主治醫(yī)生填寫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，用于海南航空評(píng)估旅客是否適宜成行。如果旅客可以運(yùn)輸，我們會(huì)根據(jù)此表中服務(wù)需求進(jìn)行安排和準(zhǔn)備，為旅客提供安全和舒適的服務(wù)。2）The PHYSICIAN ATTENDING the incapcitated passenger is requested to ANSWER ALL QUESTIONS ,Enter a cross “×”in the appropriate “yes”or “no”boxes, and/

3、or give precise concise answers.請(qǐng)病患/殘疾旅客的主治醫(yī)生按要求回答以下所有的問(wèn)題，在相應(yīng)的“是”或“否”的框中打“×”，并且/或者給予精確簡(jiǎn)練的回答。3）COMPLETING OF THE FORM IN BLOCK LETTERS OR BY TYPEWRITER WILL BE APPRECIATED請(qǐng)用黑粗字體填寫此表，或者用打印機(jī)打印，要求不留空白項(xiàng)。4）The form must be returned to Hainan Airlines booking office where passenger purchase the ticket

4、s.此表填寫完成后必須交還給海南售票部門。MEDAø1PATIENTS NAME ,SEX,AGE患者姓名，性別，年齡MEDAø2ATTENDING PHYSICIANS name and adress主治醫(yī)生姓名，地址，ATTENDING PHYSICIANS telephone contact主治醫(yī)生聯(lián)系電話辦公電話Business: 家庭電話Home:MEDAø3MEDICAL DATA醫(yī)療信息DIAGNOSIS in details (including vital signs)診斷詳細(xì)資料（包括重要癥狀）Day/month/year of first s

5、ymptoms第一次癥狀發(fā)生的時(shí)間 日/月/年Date of opration手術(shù)日期：Date of diagnosis診斷日期：MEDAø4-PROGNOSIS for the flight(s): 根據(jù)癥狀對(duì)疾病在飛行中的結(jié)果進(jìn)行預(yù)測(cè)MEDAø5-Contagious AND communicable disease? 是否有傳染性疾?。?No否 Yes是 Specify詳細(xì)說(shuō)明: MEDAø6-Would the physical and/or mental condition of the patient be likely to cause distr

6、ess or discomfort to other passengers? 患者的身體和/或精神狀況是否會(huì)對(duì)其他旅客造成危害或引起其他旅客不安或不舒適？ No 否 Yes是 Specify詳細(xì)說(shuō)明: MEDAø7-Can patient use normal aircraft seat with seatback placed in the UPRIGHT position when so required? 當(dāng)飛機(jī)因安全需要調(diào)直座椅靠背時(shí)，患者是否可以使用普通客艙座椅？ Yes 是 No否 MEDAø8-Can patient take care of his own

7、needs on board UNASSISTED (including meals, visit to toilet, etc.)?在飛機(jī)上，患者是否可以照顧自己（包括進(jìn)餐，去洗手間等）？ Yes是 No否 If not ,type of help needed:如旅客不能照顧自己，請(qǐng)?zhí)顚憛f(xié)助需求： MEDAø9-If to be ESCORTED, is the arrangement Satisfactory to you? 如果旅客需要進(jìn)行陪護(hù)，您認(rèn)為陪護(hù)人員的安排是否合適？ Yes是 No否 If not ,type of escort proposed by YOU：如果

8、您認(rèn)為不妥，請(qǐng)說(shuō)明您的陪護(hù)人員安排建議： MEDAø10-Does patient need OXYGEN equipment in flight? 患者在機(jī)上是否需要氧氣設(shè)備？ No否 Yes是 （if yes, state rate of flow 如果需要請(qǐng)說(shuō)明流量） Liters per minute升/分鐘 ；continuous是否持續(xù)? No否 Yes是 MEDAø11-Does patient need any MEDICATION（*NOTICE）, other than self-administered, and/or the use of speci

9、al apparatus such as respirator, incubator, etc.?除了患者自己準(zhǔn)備的藥物，患者是否還需要一些藥物，和/或是否需要使用特殊設(shè)備，比如呼吸器、恒溫箱等？(a) on the GROUND while at the airport(s) 在機(jī)場(chǎng)候機(jī)樓地面：No否 Yes是 Specify詳細(xì)說(shuō)明: (b) on the board of the AIRCRAFT 在飛機(jī)上客艙內(nèi)：No否 Yes是 Specify詳細(xì)說(shuō)明: MEDAø12MEDAø13-Does patient need HOSPITALISATION? 以下兩種情況

10、，患者是否需要住院治療？ (if yes, indicate arrangements made or, if none were made, indicate“NO ACTION TAKEN”) （如果“是”，請(qǐng)簡(jiǎn)要說(shuō)明已進(jìn)行的住院安排情況；如果“否”，請(qǐng)注明“沒有進(jìn)行安排”）(a) during long layover or night stop at CONNECTING POINTS en route 在銜接站長(zhǎng)時(shí)間停場(chǎng)或過(guò)夜停留：No否 Yes是 Action安排情況: (b) upon arrival at DESTINATION：到達(dá)終點(diǎn)站：No否 Yes是 Action 安排

11、情況: MEDAø14MEDAø15-Other remarks or information in the interest of your patients smooth and comfortable transportation: 為了使旅客能夠更加舒適、順利進(jìn)行航空運(yùn)輸，請(qǐng)?zhí)峁┢渌嚓P(guān)信息：None無(wú) Specify if any其他的詳細(xì)說(shuō)明： MEDAø16-Other arrangements made by the attending physician:主治醫(yī)生的其他安排： NOTE:Cabin attendants are NOT autho

12、rized to give special assistance (e.g. lifting) to particular passengers, to the detriment of their service to other passengers. Additionally, they are trained only in FIRST AID and are NOT PERMITTED to administer any injection, or to give medication.備注：不允許客艙乘務(wù)員向特殊旅客提供某項(xiàng)特別的幫助（如抬或架起）,而對(duì)其他旅客造成損害。此外，客艙

13、乘務(wù)員僅僅只進(jìn)行了急救培訓(xùn)，不允許進(jìn)行注射或提供藥物救治。IMPORTANT:FEES, IF ANY, RELEVANT TO THE PROVISION OF THE ABOVE INFORMATION AND FOR CARRIER-PROVIDED SPECIAL EQUIPEMNT ARE TO BE PAID BY THE PASSENGER CONCERNED.重要說(shuō)明：關(guān)于以上所提到的供應(yīng)品和承運(yùn)人提供的特殊設(shè)備，這些費(fèi)用由患者支付。Date日期：Place地點(diǎn)：Attending Physicians Signature主治醫(yī)生簽名：PASSENGERS DECLARATIO

14、N旅客聲明“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 consideration thereof I hereby relieve the physician of his /her professional duty of con

15、fidentiality in respect of such information,and agree to meet such physicians fees in connection therewith.I take note that,if accepted for carriage, my journey will be subject to the general conditions of carriage/tariffs of the carrier concerned and that the carrier does not assume any special liability exceeding those conditions /tariffs.I agree to reimburse the carrier upon demand for any special expenditures or costs in connections with my carriage .”(where needed ,to be read by /to the passenger, dated and signed by him/her or on his/her behalf.為了我旅程順利成行，我授權(quán) （指定的醫(yī)生姓名）