Kenya Airways Medical Information - Medif Card
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2Ref No KQ/HR/02/MOH
MEDICAL & OCCUPATIONAL HEALTH MANUAL
VERSION 02
MEDICAL INFORMATION – MEDIF CARD
To be completed by KQ APPOINTED PMC DOCTOR or ATTENDING PHYSICIAN
This form is intended to provide CONFIDENTIAL information to enable the airlines’ MEDICAL Department to assess the Fitness of the
passenger to travel. If the passenger is acceptable this information will permit the issuance of the necessary directives designed to provide for
the passengers’ welfare and comfort. The PHYSICIAN ATTENDING the incapacitated passenger is requested to ANSWER ALL
QUESTIONS. Enter a cross „X‟ or tick „√‟ in the appropriate ‘Yes or No’ Boxes and/or give precise concise answers). PLEASE COMPLETE
THIS FORM IN BLOCK LETTERS
This form must be returned to the Head of Medical and Occupational Health
KQ
PATIENTS Title
/ Name
SEX
AGE
MEDA01
FLIGHT DETAILS
FROM
TO
DATE
MEDA02
RELEVANT MEDICAL HISTORY / OTHER RELATED MEDICAL CONDITIONS
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
COMPULSORY TESTS
RESULT
Date Checked
All Adults
Blood Pressure
Diabetics
Random Blood Sugar
Respiratory / Cardiac cases
Oxygen Saturation in room air (%) [current]
Pregnant Mothers
Gestational Weeks
Due date
Complications so far
Co-morbidities
CNS Cases
Glasgow Coma Scale Score
Any other additional results
Current Hemoglobin Level (Compulsory);______________________ Date Checked; ____________________________
Please note: This document is only valid if tests are completed within 5 days of submission of form
DETAILED DIAGNOSIS
_________________________________________________________________________________________________
__________________________________________________________________________________________________
CURRENT CLINICAL STATUS ___________________________________________________________________________
_______________________ ______________________________________________________________________________
MEDA03
DIAGNOSIS/REASON FOR
RECENT SURGICAL
SURGERY.
HISTORY
DATE SURGERY DONE
MEDA04
PROGNOSIS under reduced atmospheric and Oxygen pressure at the flight altitude.
MEDA05
Any Contagious AND communicable diseases?
NO
YES
Specify
MEDA06
Would the physical and /or mental condition of the patient cause
NO
YES
distress or discomfort to other passengers?
Specify
MEDA07
Can patient use normal aircraft seat with seat back placed in upright
NO
YES
position when so required?
Specify
MEDA08
Can patient take care of his own needs on board
If not, indicate the kind of help needed
UNASSISTED* (Including meals, visit to toilet, etc)?
YES
NO
If yes, indicate the type of meal/s needed
Does the passenger require special meals on board?
YES
NO
Kenya Airway’s medical clearance process begins with a declaration of illness or incapacitation by a passenger at first point of contact with the
company. It involves getting information from your medical doctor or other healthcare provider. KQ will uphold professional ethics and high
integrity, and reserves the right and discretion to accept, reject or cancel any medical clearances received. Medical clearance will be done based on
PMC conditions as defined by the airline according to IATA guidelines.
Revision 01
Effective Date 01 July 2013
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