1、诊断证明书1.旅客姓名 2.年龄 3.性别 4.住址( 或工作单位) 5.电话 6.航程：航班号 日期 月 日自 至 联程：航班号 日期 月 日自 至 7.诊断结果： 8.症状、程度、愈后( 如系孕妇需注明预产期) 注：(1)上述7、8 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残旅客提供必要的服务时作为参考。程度症状 无 轻度 中等 严重 备注贫血呼吸困难疼痛血压附注：(如有膀胱、直肠障碍或在飞行中需特殊餐食及药物医疗处理情况等，请予以列明)10.需要何种乘坐姿势(将下列适用的项目用 O圈起)、乘坐姿势 1.使用机上一般座椅 2.使用机上担架设备陪伴
2、人员 医生，护士、其它人员(具体列明)，不需要轮椅 要，不要上下飞机时担架 要，不要救护车 要，不要已参阅背面的参考资料，我院诊断认为，该旅客的健康条件在医学上能够适应上述航空旅行的要求，无传染疾病，也不至造成对其它旅客的不良影响。医师： 电话： 签字 医疗单位(盖章)年 月 日参考资料下属内容仅供医生在判断病人是否适于航空旅行时的参考一. 机上条件1 飞机具有密封，增压客舱。舱内气压相当于2300公尺(7000 英尺)高度的大气压力，因此能引起体腔内气体的膨胀，同时也造成轻度的缺氧状态。2 飞机在飞行中会有轻微的颠簸及震动。3 机上服务人员只受过一般的急救训练，但不允许为病人注射。同时，在飞
3、行途中机上服务人员需担负整个飞机上的服务工作，无暇更多地特别照顾病人。4 机舱内的活动范围和舒适程度受到机舱技术设备的一定限制。二. 处于下述状况的病人，一般不适于航空旅行：1 处于极严重或危急状态的心脏病患者。如严重的心力衰竭；出现紫绀症状或心肌梗塞者(在旅行前六周之内曾发生过梗塞者 )。2 出生不满14天的婴儿。3 孕妇。怀孕期超过36 周者。( 怀孕期在36 周以内超过 32周的孕妇乘机，需具有医生在72 小时之内签署的诊断证明书 )。4 血色素量在50%(Hb8g/dl)以下的贫血病人。5 严重的中耳炎，伴随有耳咽管堵塞症的患者。6 近期患自发性气胸的病人或近期做过气胸造影的神经系统病
4、症的患者。7 大纵隔瘤，特大疝肿及肠梗阻的病人；头部损伤，颅内压增高及颅骨骨折者；下颌骨骨折最近使用金属线连接者。8 酒精或其他毒品中毒者；患有精神病；易于伤人或自伤行为者。9 近期进行过外科手术，伤口未完全愈合者和产妇后不满二周者。10 在过去30 天内患过脊髓型脊髓灰质炎患者。11 下列传染病或疑难病患者：霍乱、伤寒、付伤寒、发疹性斑诊伤寒、痢疾、天花、猩红热、白喉、鼠疫、流行性脑炎、脑膜炎、开放期的肺结核及其他传染病。12 带有传染性或损伤、使其它旅客感到厌恶的皮肤病患者。13 带有严重咯血、吐血、呕吐、呻吟症状的患者。MEDICAL CERTIFICATE FOR AIR TRAVEL
5、1.Passengers Name 2.Age 3.Sex 4.Address: 5.Telphone: 6.Airlines,flight number and date From to (If interline: Carrier From to 7.Diagnosis： 8.Symptoms,severity and immediate prognosis(In case of a pregnant woman, put the expected delivery date) Note: i) The medical terms used in Item 7 and 8 above sh
6、ould also be explained in simple words.ii) The following table should serve as a guidance for cabin attendants in the treatment of the invalid passengers in flight. Please check the appropriate column.SeveritySymptomsNIL Mild Moderate Severe RemarksAnemiaDyspneaPainBlood Pressure9.Additional remarks
7、(If necessary, state any malfunction of the bladder or bowels, or any special diet or medication required in flight) 10.Meas of carriage (encircle an appropriate item in each column)Seating Normal Passenger Seat. Stretcher installed in CabinAttendants Not required, Doctor, Nurse, Others (specify)Whe
8、el chair Not required, RequiredFor boarding and deplaning Stretcher Not required, RequiredAmbulance Not required, RequiredHaving read the guiding principles on the reverse side of this page, I diagnose that this passenger is medically fit to undertake the above journey by air; is non-infectious and
9、has no malady which might cause distress, inconvenience or embarrassment to other passengers.Doctors Name (Signature) Issuing Date GUIDANCE FOR THE PHYSICIANThe following factors to be considered when diagnosing the physical and mental fitness for air travel:1. Cabin conditions:a) The air pressure w
10、ithin the pressurised cabin may fall to the equivalent of a height of 2300 meters (7000ft) with consequent expansion of any gas within body cavities and reduction of alveolar oxygen pressure.b) Technical limitations of space and comfort.c) Cabin attendants are trained only in First Aid and not allow
11、ed to give injections.Furthermore, they not expected to pay particular attention to the invalid people to the detriment of service to other passengers.d) The activity range and comfortable degree are specially restricted by the technological equipment in the cabin.2. Person under following condition
12、 are generally considered unfit for air travel:a) Those suffering from severe and critical heart disease: e.g. severe cardiac failure, Cyanotic condition, or myocardial infarction.(those who have had an attack within the past 6 weeks are not acceptable.)b) Infants within 14days of birth.c) Pregnant
13、women in their 36th week or more(women in their pregnancy more than 32nd to 36th week may be acceptable if presenting a doctors certificate signed within 72 hours)d) Anemic persons (hemoglobin concentration less than 50%)e) Those suffering from severe otitis media with blockage of the Eustachian tub
14、e.f) Those who suffered from spontaneouse, pncumothorax or have had ence-phalopneumography recently.g) Those suffering from mediastinal tumores extremely large hernias, intestinal obstruction, head injuries resulting in cranial hypertension, or fracture of the skull, and those with permanent wiring
15、in the jaws.h) Alcoholics and other toxic patients, or those mentally ill, who are hazardous to others and/or to himself.i)Those not completely cured from a recent operation and women who are in the condition of afterbirth not more than 2 weeks.j)Those having suffered from poliomyelities within the
16、past 30 days and those suffering from bulbar poliomyelities.k) Those suffering from following epidemics and suspected patients; cholera; typhoid fever; paratyphoid fever; cruptive typhus; dysentory; smallpox; scarlet fever diphteria; plague; epidemic meninge encephalitis; encephalitis; tuberculousis (infectious); and other epidemics.l) Those with skin lesion which is contagious or unpleasant to others.m) Those with severe symptoms of hemoptysis, melena, vomiting or groan
