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F-IH017 版本：AB
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MEDICAL CLEARANCE FORM
This form is intended to provide CONFIDENTIAL information to enable the airline’s MEDICAL Department to assess the
fitness of the passenger to travel. If the passenger is acceptable for air travel, this information will permit the issuance of the
necessary directives designed to provide for the passenger’s welfare and comfort. The PHYSICIAN ATTENDING of the
passenger is requested to ANSWER ALL QUESTIONS in ENGLISH or TRADITIONAL CHINESE.
Enter a Check Ҭ in the appropriate boxes, and / or give precise concise answers.
MEDA 01
PASSENGER
Name：
Gender： □ Male □ Female
Age：
Flight info. ：
□ Wheelchair □ Stretcher
Weight：
MEDA 02
ATTENDING
PHYSICIAN
Name：
Contact Number Business：
Hospital Clinic Affiliation：
MEDA 03
DIAGNOSIS in details：
Date of diagnosis：
Date of first symptoms：
Date of Operation：
Vital Signs：
GCS：________ BP：________ RR：______ HR：______ Temp：______°C SpO2：_____% Hb：_____
Medical certificate attached【mandatory for all applications】
□ No □ Yes
Summary of medical records attached【operation or admission within 2 weeks】
□ No □ Yes
MEDA 04
Fitness for the Flight(s)？
□ Fit to Travel □ Not Fit to Travel, Specify：
MEDA 05
Contagious AND Communicable Disease？Specify if YES：
□ No □ Yes
MEDA 06
Would the physical and／or mental condition of the patient be likely to cause distress or discomfort to
other passengers or one’s self*？
Specify if YES：
□ No □ Yes
MEDA 07
Can passenger use normal aircraft seat with seatback placed in the UPRIGHT position when required？
□ No □ Yes
MEDA 08
Q1. Can passenger understand and respond to cabin crew’s safety instructions and assist one’s own
evacuation in the event of emergency？ If not, the passenger must be escorted.
Q2. Can passenger take care of his own needs on board UNASSISTED 【including meals, visit to toilet,
administer medications, etc.】？ If not, the passenger must be escorted.
□ No □ Yes
□ No □ Yes
MEDA 09
Q1. Does the passenger require an ESCORT？
Q2. If to be ESCORTED is the arrangement satisfactory to you？
□ No □ Yes
□ No □ Yes
Type of escort proposed by YOU：□ Travel companion □ Nurse □ Doctor □ Nurse & Doctor
MEDA 10
Does passenger need OXYGEN？**
□ No □ Yes
Period of usage
□ On Ground
□ During Flight
Oxygen flow rate
□ 2 L/MIN □ 4 L/MIN
□ 2 L/MIN □ 4 L/MIN
Continuous
□ No □ Yes
□ No □ Yes.
Estimated amount of OXYGEN：_____________BT