诊断证明书 某航空公司特殊旅客资料模板

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.

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

轮椅Wheelchair 要Need 不要No Need 上下飞机时Deplane or enplane

担架Stretcher 要Need 不要No Need 救护车Ambulance 要Need 不要No Need

已参阅下面的资料，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，也不致造成对其他旅客的不良影响。After referring the under documents,

we make a diagnosis: the health condition of this passenger meets the requirements of air travel, he/she hasn't communicable disease, and doesn’t influence other passengers.

医师（签字）Physician (signature)：电话Tel：

医疗单位（盖章）Medical Unit(seal)

日期（年月日）Date(Y./M/D)：

参考资料（下述内容仅供医生在判断病人是否适于航空旅行时的参考）References (The following contents are only for physician's reference on the fact whether a patient is suitable for air travel or not)

一、机上条件I. Conditions on board：

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。The airplane's cabin is sealed

and pressurized. Cabin pressure is equivalent to the atmospheric conditions at 2300 meter (7000 ft), which cause expansion of body cavities and mild anaerobic conditions.

2．飞机在飞行中会有较大的颠簸及震动。Great jolt and vibration may be occurred while flying. 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，无暇更多地特别照看病人。The cabin crew are only

trained for common first aid, and not allowed for patient injection. And that, the cabin crew should be responsible for service during flight, so they have no time to especially attend patients more. 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。Activities space and comfortable will be limited by technique and equipment in cabin.

二、处于下述状况的病人，一般不适于航空旅行II. The people, who is in the following

conditions, isn't suitable for air travel：

1．处于极严重或者危急状态的心脏病患者。如严重的心力衰竭，出现紫绀症状或者心肌梗塞者（在旅行前六周之内增发生过梗塞者）。The cardiopath is of severe case or in critical status,

e.g. severe heart failure, cyanosis, or myocardial infarction (The case of myocardial infarction occurred within six weeks before traveling)