Fillable Cathay Pacific Passenger Medical Clearance Form (Meda)

PASSENGER MEDICAL CLEARANCE FORM (MEDA) – PART 2

This form is intended to provide CONFIDENTIAL information to enable the airline’s MEDICAL Department to assess the fitness of the

To be completed

passenger to travel as indicated in Part 1. If the passenger is accepted, this information will permit the issuance of the necessary

by ATTENDING OR

directives designed to provide for the passenger's welfare and comfort. The DOCTOR ATTENDING OR TREATING the passenger is

TREATING

requested to ANSWER ALL QUESTIONS. (Enter a cross 'X' in the appropriate 'yes' or 'no' boxes, and/or give concise answers).

MEDICAL DOCTOR

Please also complete Part 3 of this form if the passenger has any of the following: Cardiac conditions, Pulmonary conditions,

Psychiatric conditions, Seizures, a Fracture or Peanut Allergy. COMPLETION OF THE FORM IN BLOCK LETTERS WILL BE

(IN ENGLISH

)

APPRECIATED

MEDA 01

Passenger’s Surname: _________________________________ First Name: ______________ Sex: _______ Age: ________

Attending or Treating Medical Doctor’s Name _________________________________________________________________

MEDA 02

Address ____________________________________________________________________________________________

Telephone No. (Business) ____________ (Home or Mobile) ___________ Email: __________________________________

Medical Diagnosis:____________________________________________________________________________________

Details of current medical conditions (including vital signs) :

MEDA 03

___________________________________________________________________________________________________

____________________________________________________________________________________________________

Date of first symptoms: _____________ Date of diagnosis: ____________ Date of operation: ____________



MEDA 04

Prognosis for the trip: ________________________________________ Good

Stable

Unstable

Poor





Does the passenger have any contagious OR communicable disease?

Yes

MEDA 05

If yes, please specify: ________________________________________________________________



Would the physical and/or mental condition of the passenger cause a safety risk to other passengers or

Yes

MEDA 06

them self? If yes, please specify:_____________________________________________



Can the passenger use a normal aircraft seat with seatback placed in the UPRIGHT position?

Yes



Can the passenger use a normal aircraft seat with both the KNEES BENT?

MEDA 07

Yes



If no, can the passenger rest his/her leg on the ground during the flight?

Yes



Can the passenger comprehend and respond appropriately to safety instructions from cabin crew and/or

Yes

assist in their own evacuation from the aircraft in the event of an emergency?



If not, type of help needed: ____________________________________________________________

MEDA 08





Can the passenger take care of his/her own personal needs on board UNASSISTED* (including meals,

Yes

visit to toilet, administering of medications etc)?

If not, type of help needed: ____________________________________________________________





Does the passenger require an ESCORT?

If yes, type of escort proposed by YOU:

Yes









Nil

Travel Companion / Assistant

Nurse

Medical Doctor

Type of assistance required from escort:





Yes

•

assistance in comprehending and responding appropriately to safety instructions from cabin crew

MEDA 09



and/or assist passenger to evacuate the aircraft in the event of an emergency

•



personal care needs e.g. eating/drinking, administration of medications, elimination functions

Yes

including assistance inside the lavatory

•

Other _________________________________________________________________________

Does the passenger need OXYGEN**

(a) On the GROUND:

Litres per minute:

Continuous?









(Cathay only provides flow rates of 2

Yes

MEDA 10

or 4 litres per minute of constant flow

(b) On board the AIRCRAFT:

Litres per minute:

Continuous?

oxygen by mask or nasal cannula)



Yes

(a) On the GROUND while at the



Specify:________________________________

airport(s)

Yes

Does the passenger need any

______________________________________

(b) On board of the AIRCRAFT

MEDICATION* other than those self

Specify_________________________________

MEDA 11



administered?

Yes

_______________________________________

 ( c) Can it be administered by the

Specify_________________________________





_______________________________________

escort?

Yes

(a) On the GROUND while at the



Specify:________________________________

airport(s)

Yes

_______________________________________

Does the passenger need any medical

(b) On board of the AIRCRAFT

Specify:________________________________



devices such as POC***, CPAP,

Yes

_____________________________________

MEDA 12

suction, respirator, etc**?

Specify:________________________________

(Note all medical equipment onboard must



______________________________________

flight

Yes

be battery operated)

Specify:________________________________

(d) Not required during take-off





______________________________________

and landing

Yes

Does the passenger need HOSPITALISATION upon arrival?



Yes

MEDA 13

(If yes, indicate arrangements made or if none were made, indicate “NO ACTION TAKEN”)

Action: ____________________________________________________________________

NOTE: The attending doctor is responsible for all arrangements.

Specify other information in the interest of the passenger’s smooth and comfortable transportation**:

MEDA 14

______________________________________________________________________________________________________

____________________________________________________________________________________________________

Specify other arrangements made by the attending doctor:

MEDA 15

____________________________________________________________________________________________________

Note:

(*)While our cabin crew will do everything possible to provide assistance to passengers during the flight, please note that we are unable to provide passengers with

any assistance for personal care needs such as feeding, elimination functions including assistance inside the lavatory or other personal care needs. Additionally,

cabin crew are trained only in FIRST AID and are NOT PERMITTED to administer any injection or medication.

(**) IMPORTANT - Fees, if any, relevant to the completion of this form and/or for the provisions of medical devices are the responsibility of the passenger

concerned.

(*** )Portable Oxygen Concentrator (POC) Please complete the “Physician Statement: POC” form

Date:

Print Doctor’s Name:

Doctor’s Signature:

Reviewed: 22 August 2014

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