诊断证明书.doc

诊 断 证 明 书 Certificate of Diagnosis 1．旅客姓名Name of Passenger： 2．年龄Age： 3．性别Sex： 4．地址及联系方式Add. and contact： 5．航程Routing：航班号Flight No. HU 日期Date 月Month 日Day 自From 至to 联程Via：航班号Flight No. 日期Date 月Month 日Day 自From 至to 6．诊断结果Result of diagnosis： 7．症状、程序、预后（如系孕妇需注明预产期）Symptom, process, prognosis (indicate expected date of childbirth, if pregnant woman)： [注]（1）上述第6、7两项内容填写，需简单、明确。（2）下述表格中提供的内容，供机上服务人员在飞行途中为病伤旅客提供必要的服务时作为参考。[Note] (1) The above described 6 and 7 items shall be filled shortly and clearly. (2) The content described in the form under is for reference to cabin crew who offer necessary service to sick or injured passengers during flight. 程度Degree 症状Symptom 无Normal 轻度Mild 中等Moderate 严重Severe 备注Remark 贫血Anemia 呼吸困难Dyspnea 疼痛Pain 血压Blood Pressure 8．附注：（如有膀胱、直肠障碍或者在飞行中需要特殊餐食及药物医疗处理情况等，请予以列明）PS: (If suffering from bladder and recta, or needing special food and medical treatment on the flight, please list it clear) 9．需要何种坐姿（将下列适用的项目用 ○ 圈起）Which kind of seating position is needed (Enclose the following applicable items with ○)： 乘坐姿态Seating Position 1．使用机上一般座椅Taking common seat 2．使用机上担架设备Using supporting equipment 陪伴人员Attendance 医生 Doctor · 护士 Nurse · 其他人员（具体列明）Others (list in details) · 不需要 No need 上下飞机时Deplan