MEDICAL DECLARATION

Form Number : xxxxxxxx This form is intended to provide confidential information to enable the airline's
Ground Officer and Aircrew to asses the fitness of the passenger to travel by air
To be completed by and give the necessary directives designed to provide for
attending physician the passenger's welfare and comfort

Passenger's name : Address :

01 Sex :

Age : Phone :

Flight No. : Class : F / C / Y ate : e!arture "ime :

From : ###..####..####.. "o #####...##.################..#..## $dire%t &light
02
From : ##..####..#####.. "o ######.####### (ia #########..### $)ithout/)ith %onne%ting

"rans&er Flight at : ################## Flight Nbr. ##############..

iagnosis : #######################################################
+eneral Condition State o& Consiousness : %om!osmentis !re%omatose %omatose

Ph,si%al Strength : normal )ea- !aral,sed

S!e%i&, : ########################################.
########################################.
lood Pressure : ######...### eart ate : ######....###. od, "em!erature : #######..

Anemia : No Yes emoglobin ###########..............................

,s!noe : No Yes egree : mild moderate seere

0*
Pain : No Yes egree : mild moderate seere

Contagious and %ommuni%able disease 3 : No Yes S!e%i&, : #####################

4s !atient in an, )a, o&&ensie to other

!assenger 3 $smell a!!earan%e %ondu%t : No Yes S!e%i&, : #####################

e%ent heart atta%- 3 : No Yes S!e%i&, : ######## 5hen3

#########
e%ent o!eration 3 : No Yes S!e%i&, : ######## 5hen3
#########
6al&un%tion o& the bladder or bo)els : No Yes S!e%i&, : #####################

7ther S,m!toms : ###################################################

oes !atient need intraenous treatment/nutrition during &light 3 No Yes

oes !atient need ox,gen during &light 3 No Yes S!e%i&, : 9 ate o& &lo) ##########. /minute

08 9 Continuous No Yes

oes !atient need s!e%ial a!!aratus su%h res!irator in%ubator et% No Yes

oes !atient need medi%ation during &light 3 No Yes S!e%i&, :####################.#.

0; Prognosis &or the tri! : #################################################...

ased on the in&ormation aboe and haing read the guiding !rin%i!les oerlea&

4 here)ith de%lare that this !assenger is F4" <N F4" = to underta-e the aboe
>ourne, b, air !roided that the !assenger is gien the &ollo)ing arrangements or is treated as
&ollo)s : A egree o& ambulation :

Sitting %ase 5heel %hair %ase Stret%her %ase

 "he !assenger )ill not be es%orted / )ill be es%orted b, :

o%tor Nurse 7ther

$ all stret%her %ases must be es%orted 
C S!e%ial arrangements needed $i.e. ox,gen et% )hi%h should be !roided b, Sri)i>a,a Air
##########################################################
##########################################################

N ot e  ! li gh t A tt en da nt s a re n ot a ut ho ri "e d t o g iv e s pe ci al a ss is ta nc e t o # mp or ta nt  ! ee s i f a ny$ r el ev an t t o t he
p ro vi si on o f t he particular passengers$ to the detriment of their service to other above information and
for Sriwi%aya Air & passengers provided special
e(uipment are to be paid Additionally$ they are trained only in !irst Aid and are not by the
passenger concerned
permitted to administer any in%ection or to give medication

Attending !h,si%ian's name : A!!roed b, Su!erisor 7n ut, : Piha- Airlines

Address : ate : Name :

Phone : Signature : ate :

Ca! umah Sa-it