医疗诊断证明书-HainanAirlines.doc

海航医疗诊断证明书 Hainan airlines (HU)MEDICAL INFORMATION SHEET – (MEDIF) 诊 断 证 明 书由主治医生填写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 necessary directives designed to provide for the passenger’s welfare and comfort.此表中提供的必威体育官网网址信息，用于海南航空评估旅客是否适宜成行。如果旅客可以运输，我们会根据此表中服务需求进行安排和准备，为旅客提供安全和舒适的服务。 2）The PHYSICIAN ATTENDING the incapcitated passenger is requested to ANSWER ALL QUESTIONS ,Enter a cross “×”in the appropriate “yes”or “no”boxes, and/or give precise concise answers.请病患/残疾旅客的主治医生按要求回答以下所有的问题，在相应的“是”或“否”的框中打“×”，并且/或者给予精确简练的回答。 3）COMPLETING OF THE FORM IN BLOCK LETTERS OR BY TYPEWRITER WILL BE APPRECIATED请用黑粗字体填写此表，或者用打印机打印，要求不留空白项。 4）The form must be returned to Hainan Airlines booking office where passenger purchase the tickets.此表填写完成后必须交还给海南售票部门。MEDA?1PATIENT’S NAME ,SEX,AGE 患者姓名，性别，年龄MEDA?2ATTENDING PHYSICIAN’S name and adress 主治医生姓名，地址，ATTENDING PHYSICIAN’S telephone contact 主治医生联系电话办公电话Business: 家庭电话Home:MEDA?3MEDICAL DATA 医疗信息 DIAGNOSIS in details (including vital signs)诊断详细资料（包括重要症状） Day/month/year of first symptoms第一次症状发生的时间 日/月/年 Date of opration 手术日期： Date of diagnosis诊断日期：MEDA?4-PROGNOSIS for the flight(s): 根据症状对疾病在飞行中的结果进行预测MEDA?5-Contagious AND communicable disease? 是否有传染性疾病？ No否 □ Yes是 □ Specify详细说明: MEDA?6-Would the physical and/or mental condition of the patient be likely to cause distress or discomfort to other passengers? 患者的身体和/或精神状况是否会对???他旅客造成危害或引起其他旅客不安或不舒适？ No 否□ Yes是 □ Specify详细说明: MEDA?7-Can patient use normal aircraft seat with seatback placed in the UPRIGHT position when so required? 当飞机因安全需要调直座椅靠背时，患者是否可以使用普通客舱座椅？ Yes 是□ No否 □MEDA?8-Can p