AM ae AR Qogcul . Ss SAUDIA MEDIF STANDARD MEDICAL INFORMATION FORM FOR AIR TRAVELars MEDIF eben SAWOARD MEDIAL FORMATION FORM FORA TRAE o sates ore ae pee A uso —Po acs th EF FW tee i LK EES or MPEMTER en ogi fem. A | one saraas me i [oiling es See ds seer concer ining ine ATURE bitty eocaLcarancencqunen? = [| Giver ont oe “OO ethane TRO BI pe a omar ‘oesona qaliition, segments pees Sarat seein sonar oman Pe a = wacom» —] ae | OSE EEE | | iestemnevaince ~ “—euestouymr cea” an r Comgmies ae “ - =( + * ™ conditions which can be obtained from the WoW Wes woic O Oo = y, | eee mee | ed] oo «1 2 | “= Ca © rst oe ce cor eam i oe et one cone 7 Ta RF era oo EN ‘wets ene? Ce pire etek cree ane eee tn oer ie poe atsipnc a — pmgmestetings =X [—] »[] me Sond Amgeesbrasitnse =] & te waeetiacrcons aminiisteonitns wf] #[ ee Semin ren ‘oreo =~ raat RNA fa esas ncn neo ECE ‘ARANGEMERTS NEEDED shes ~]. * rie ah weg par ml ste ape Pat special wale. special seating. eget, 'SPECCIAL EQUIPMENT sacha oxygen ot, aways requires completion of Part 2 overaat x. | Sect Gut ntr2 co Tas nace nA aE i or aga aa rae ama) es [ae what tt ps com he ‘meats | [ae 1 ] ] ' a oI ea an ae sae ‘ 1 ] at = MSSENGERS DECLARATION erty auto ‘ame fmm Pica topo he ans with the formation equ by the in medal pron or he pare of eemnng ny Oe Tor cage by and codeine heey reve at pn efi her pfesioal ay of ‘oni inept a chines, adage oe ah octane ink steht acted far ringn my june be abn tthe gow candtn of riage a othe cain) concerned and ht th cris) do ot came 2 spl ity xading he condone tre | Fam prepared, at ny nm kbar any consequences which cig by ima hae for myst ath adele he cas empyees srs and agents om ay ii for such consequnes. ages o rnb the cari upon demand fr anys ependtures or tn conection wth ay cariage, ire ede beady tthe asenge ate nds yh The Wiser bel, Ta oa Tasca aaMEDIF coca ronan st Geaitiaansy PART 2 ‘fem tndadtprde OATOOTAL amin oe es MEAL Depart as Dehcopd Taetal panne Sa he pete ra ‘eft rt o Poa sles tency Se Sedona pee eer a The PHYSICIAN ATTENDING the disabled passenger is requested to Answer All Questions. (tet a crass "X" in the Mem Re bole gi pe (xb {tect TS POT en enn om or ie Tans a, won| is Sea. ‘et nec Slime des ono Tai es ort Soa ioe Telephone Contact | roe comme ees Wee TOs mas Seely om CC] senses | cig -— ‘sthe dagnossintcated in Pat (3) Wwe [| Ho Day! Moath/Year of the fist symptoms Date of diagnosis Bese ey eeneieetaeas wenaos | races rhe eons | conagins A connie eae? mel] L_] sete ‘pat yy OEE a MEDAGE | pasges? 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(}s Fo hl test? Jeane Joggers [egw gets ge te sontepemti onan e-reaanaatampene [es [wo 2. Myc tin (ols [0 oe canons Cs [p< rs et sete? Cos [pe ret ea es onan soma bpescn tit sk acetnmdpaaardnb sitet pls! SN 4 ca ate a) hes tet poe? + hep once wh mete no rete tps? Sermadteshwbinpsatetrs [—] Somattesh tigen [—]shamactba tet 5. scope Cos (Je tee es Cole [Efe nse RESPIRATORY CONDITION [=] ‘FYES, FILL OUT ITEMS BELOW + Heteptetintmantictgeer §—s[_] [_] + sods me ence: Jesomar [foment 1 at we ees 9, *, ss, enelean + wep nO? jes 0 + vate odie ct? ins [0 + cote perak oo natanenlecrdat 0-nttewte yee [es [fo + Hate pice oh conn cit esc? ss Eo trate tte ole? PSYCHIATRIC AND NEUROLOGICAL CONDITIONS ]veL) ES mu eur ews aetow 7 Pt Caos casted peantcutasiae’ [ai ia] + sheen cameo eae? wef] mL] esata 2 ie Darr + vonedot + feenottenre? ware + herrea ms? ce eeaecann oo specity if passengeris fit fortravet v=] vo[—] Se pmantdeamndwaereae tuaes wna mT ts ERLE TOTPROWSONOF TH AEE nln STAID ad to provide sistance to the atndns operat tn oye bpp eet errs tpt aad ‘ttle and they are NOT PERMITTED to administer any injection e to give any EOE SIO EE NS der. Tar cor ae "ea Pc aN NOE Tio lid fron (10) dye om the date fhe Doc gat