诊断证明书29363.pdf

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1、诊断证明书 Certificate of Diagnosis 1.旅客姓名 Name of Passenge: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,prognosi

2、s(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

3、service to sick or injured passengers during flight.程度 Degree 症状 Symptom-无 Normal 轻度 Mild 中等 Moderate 严重 Severe 备注 Remark 贫血 Anemia 呼吸困难 Dyspnea 疼痛 Pain 血压 Blood Pressure 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

4、 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 O)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 detai

5、ls)不需-要 No need 上下飞机时 Deplane or enplane 轮椅 Wheelchair 要 Need 不要 No Need 担架 Stretcher 要 Need 不要 No Need 救护车 Ambulance Need 不要No Need 已参阅下面的资料，我院诊断认为：该旅客的 勺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

6、 the requirements of air travel,he/she hasnt 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 月曰)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 physicians reference on the fa

7、ct 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 airplanes cabin is sealed and pressurized.Cabin pressure is equivalent to the atmospheric conditions at 2300 meter(7000 ft),which cause exp

8、ansion 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，无暇更多地特另 V 照看病人。The cabin crew are only trained for common first aid,and not allowed for patient injection.And that,

9、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 conditi

10、ons,isnt 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，岀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)2.出生不满 14 天的婴儿。

11、Infant under 14-day age 3孕妇。怀孕期限超过 36 周者(怀孕期在 36 周以内超过 32 周的孕妇乘机，需具有医生在 72 小时之内签署的诊断证明书)。The pregnant woman whose pregnancy exceeding 36 weeks.(If the pregnant woman,whose pregnancy is more than 32 weeks but not exceeding 36 weeks,wants to take airplane,it requires her to offer a physicians signed c

12、ertificate of diagnosis dated within 72-hour before departure.)4.血色素量在 50%(Hb8g.dl)以下的贫血病人。The patient suffering from anemia with hematochrome level below 50%(Hb 8.0 g.dL)5.严重的中耳炎，伴随有耳咽管堵塞症的患者。The patient suffering from severe tympanitis with obstruction of eustachian tubes 6.近期患自发性气胸的病人或者近期做过气脑造影的神

13、经系统病症的患者。The patient suffering from spontaneous pneumothorax recently or received pneumoencephalography(PEG)of the nervous system.7大纵隔瘤，特大疝肿及肠梗阴的病人；头部损伤，颅内压增高及颅骨骨折者；下颌骨骨折最近使用金属线连接者。The patient 11下列传染病或者疑难病患者：霍乱、伤寒、副伤寒、发疹性斑疹伤寒、痢疾、天花、猩红热、白喉、鼠疫、流行性脑 炎、脑膜炎、开放期的肺结核及其他传染病。Those are suffering from the foll

14、owing infectious disease or complicated disease cholera,typhoid fever,paratyphoid fever,typhus,dysentery,smallpox,scarlatina,diphtheria,plague,epidemic encephalitis,meningitis,pulmonary tuberculosis and other infectious diseases.12带有传染性或者损伤、使其他旅客感到厌恶的皮肤病患者。which make other passengers feel sick.13带有严

15、重咯血、吐血、呕吐、呻吟症状的患者。The patient suffering from severe emptysis,hematemesis,vomiting and groan.本单为一式三联：第一联为出票联，由出票单位留存；第二联为乘机联，交始发站值机部门留存；第三联为到达联，交到达站 服务部门留存。This form is in triplicate:the first sheet is for issuing,kept by issuing unit;the second sheet is for flight,kept by check-in department of airp

16、ort of departure;the third sheet is for arriving,kept by the service department of airport of destination.注：13-4附表应以中英文结合印刷并交付现场使用，建议采用ISO标准A4型纸(尺寸：210X297mm)。Note:Attached Form 13-4 should be printed in Chinese and English for use on site.We suggest that the paper should adopt A4 Type of ISO standa

17、rd(Size:210297mm)x suffering from mediastinum tumour,serious hernia and intestinal obstruction;head injury,intracranial hypertension and fracture of skull;and fracture of mandible joined with wire recently.8酒精或者其他毒品中毒者；患有精神病，易于伤人或者自伤行为者。behavior or autolesionism.9近期进行过外科手术，伤口未完全愈合者和产妇产后不满二周者。complet

18、ely;it is less than two weeks after delivery for the parturient.10在过去 30 天内患过脊髓灰质炎的病人；延髓型脊髓灰质炎患者。poliomyelitis within last 30 days.Alcoholism or drug addiction;psychotic,aggressive Having a surgery recently,the wound hasnt been healed up The patient has been suffering from poliomyelitic or bulbar The patient suffering from infective or traumatic dermatosis,