1s pationt in any way offensive to other
(Paasenger ? (omall, appearance, conduct) ° ss
‘Recent heart attack 7 +
‘Recent operation ?
‘Malfunction of te bladder or boweis
Other Symptoms.
Does patient need intrevenous treaimentinutrtion during fight | 2
Does patient need exygen curing Mt ? Come) Wee. spe: ram otto...
See ee ae os
al DIRE 4 re
ini ae ieeltaa tao ieng ae
_ Nerewith declare that this passenger 's =o une : to undertake the above
umay by, pond tat ha pensanger'e gen te Ttoningaangement rs tested 0 lows :
§) Dogese of amputation:
Letra case (teat ae [7 Scorn
‘Serene
TZ) oxeter
(all sticher comes musi be escorted )
*) Some erangamant needed fs, oxygen, Wich shoul be proved by‘Sittaye A)
'o Give specie! assistance to important: Fees: 10 Oe
Beabengers tothe detriment he service other a Sg n"
‘lonely, they are veined only mn Fret Aid and ore ot ——
the nessenger concamed
renee =