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Size： Width Depth Height Period of usage Continuous 【□ Centimeter / □ Inches】 □ On Ground □ During Flight □ No □ Yes □ No □ Yes □ No □ Yes Can passenger use the medical device(s) unassisted？ Does passenger need any MEDICATION , other than self-administered ？ MEDA 12 Specify if YES： □ No □ Yes Can it be administered by the escort？ MEDA 13 MEDA 14 Does passenger need HOSPITALISATION during transit/transfer at CONNECTING POINTS If yes, indicate arrangements made： Does passenger need HOSPITALISATION upon ARRIVAL？ GA：weeks + day(s) □ No □ Yes □ No □ Yes If yes, indicate arrangements made： □ No □ Yes Is passenger PREGNANT？ MEDA 15 □ No □ Yes EDD：// Gestation：□ Single □ Multiple Other remarks, information and arrangements made： MEDA 16 Date： Place： Attending Physician s Signature： Date： Place： Passenger’s Signature： 1、 Cabin crew are NOT authorized to give special assistance to passengers such as personal care and lifting..
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