Airways Passenger Medical Form Page 2
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1
2MEDICAL INFORMATION
PART 2
TO BE COMPLETED BY YOUR DOCTOR (PLEASE PRINT IN BLOCK CAPITAL LETTERS)
Doctors/Office use only
1.
Patient's Family Name
First name
Date of birth
Sex
2.
Treating physician 's name and address
Telephone contact: Business
A/H (Mobile)
3.
Medical diagnosis (in detaiI)
Date of first symptoms
Date of diagnosis
Date of Surgery
Anemia
Nil
Mild
Moderate
Severe
Blood pressure
Dyspnoea
Ni l
Mild
Moderate
Severe
Pain
Nil
Mild
Moderate
Severe
4.
Prognosis for the journey?
Poor
Fair
Good
Excellent
5.
Any contagious or communicable disease?
Yes
No
6.
Has passenger control of:
Yes
No
bowel
Yes
No
bladder
7.
Is your patients condition (physical or mental) likely to cause distress or discomfort to other passengers?
Yes
No
8.
Has your patient
had suicidal tendencies
Yes
No
been violent or required restraint
Yes
No
become noisy or agitated
Yes
No
9.
Js your patient pregnant?
Yes
No
Expected date of confinement
Are there any pregnancy related problems?
Yes
No
Details
10.
Can your patient sit for the proposed journey with the seat fully upright?
Yes
No
If no then the patient will need a stretcher at an additional cost to the patient
11.
Can your patient
walk to and board the aircraft
Yes
No
walk to the toilet unassisted
Yes
No
use the toilet unassisted
Yes
No
feed himself/herself unassisted
Yes
No
Flight attendants are unable to give special assistance with toileting and feeding
12.
Does your patient need any treatment during the journey
Details
Yes
No
13.
Does your patient need to be accompanied?
Yes
No
Is a medically trained escort necessary?
Yes
No
14.
Will oxygen be required during the journey?
L/m Continuous
Intermittent
Yes
No
Please List
Is medical equipment to be used in flight?
15.
Yes
No
16.
Having read the guiding principals, you are of the opinion that this patient is medically FIT/UNFIT to undertake the contemplated
journey by air without causing any inconvenience or embarrassment to other passengers.
DOCTOR'S
SIGNATURE
Date
Place
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