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 :

Fro
From
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# $di
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&light
ght
02 Fro
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# $)itho
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ut/)it
)ith
h %onne%
%onne%tin
ting
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"rans&er Flight at : ################## Flight Nbr. ##############..

iagnosis : #######################################################
+eneral Condition St
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
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
air !roided that the !asseng
!assenger
er is gien the &ollo)ing arran
arrangements
gements or is treated as &&ollo)s
ollo)s :
 A egree o& ambulatio
ambulation
n:

 Si
 Sitting %ase 5heel %hair %ase Stret%her %ase
 "he !assenge
!assengerr )ill not be es%orte
es%orted
d / )ill be es%orted
es%orted b, :

 
 oo%tor Nurse 7ther  
$ all stret%her %ases must be es%orted 
C S!e%ial arrangements needed $i.e. ox,gen
ox,gen et% )hi%h should be !roided b, Sri)i>a,a Air
##########################################################
##########################################################

Note
Note  !lig
!light
ht At
Atte
tend
ndanants
ts ar
are
e no
nott au
auth
thor
ori"
i"ed
ed to gi
give
ve sp
spec
ecia
iall as
assi
sist
stan
ance
ce to #m
#mpo
port
rtan
antt  !e
!ees
es if any
any$ rele
releva
vant
nt to th
the
e prov
provis
isio
ion
n of th
the
e
 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
 Additionally$$ they are trained only in !irst Aid and are not by the passenger concerned
concerned
 permitted to adm
administer
inister any in%ection or to give m
medication
edication

  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