Download medif - Avianca

MEDIF
Medical Information Form for Special Assistance Passengers
IATA - Resolution 700 (Schedule A)
To be completed by the Passenger or Legal Guardian. Answer ALL questions.
Please PRINT or TYPE.
1. Full name:
Gender: Male
Age:
Female
Home address:
Passenger’s phone #:(Area code)
E-mail (passenger/guardian):
2. Passenger name record (TRAKER):
3. Proposed Itinerary:
Airline(s), Flight Number(s):
Class(es), date(s), segment(s), reservation status:
Trip purposes:
Work
Leisure
Medical Treatment
Other
4. Nature of disability or illness:
5. Stretcher needed on board ?
Yes
No
6. All stretcher cases must necessarily be accompanied by an escort, which must be identified below:
Escort Name:
Occupation:
Tracker (if different):
Physician:
7. Wheelchair needed?
WCHR
Yes
(Wheelchair Ramp)
Wheelchair:
Own?
Battery Type
Dry
8. Ambulance needed?
Yes
No
WCHS
No
Age:
Yes
No
If Yes, the passenger:
(Wheelchair Steps)
Foldable?
WCHC
Yes
No
(Wheelchair Carry)
Motorized?
Yes
No
* Liquid Batteries are classified as "dangerous goods”.
Liquid*
Yes
No
The passenger is responsible for contracting transfer services for: Boarding and/or Disembarking / To - From Ambulance /
To - From Aircraft. If yes, inform Ambulance Company name, phone number and contact name. Destination Address:
9. Escort / designated person needed to assist on basic needs onboard
Yes
No
Yes
No
If yes, inform name and contact information:
In case of visual and/or hearing impairment, state if escorted by guide dog.
10. Other ground arrangements needed?
Yes
No
If Yes, inform other arrangements needed:
Departure Airport:
Arrival Airport:
Transit Airport:
11. Special in-flight arrangements needed?
Yes
No
If yes, specify (special meal, extra seat, special belt, other):
Specify equipment (oxygen, stretcher, etc.):
Specify special services contracted and the person responsible for the expenses :
12. Possui FREMEC válido para a viagem?
Yes
No
Especifique o número do FREMEC:
Válido até
/
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I hereby declare that I am aware that, upon accepting to travel, I am subject to the carrier's general transportation conditions and fees, and that it
shall not undertake any special liability other than those set forth by its main activity. I further declare that I am prepared and aware to undertake all
risks and consequences an air travel may cause to my health condition, informed by myself. I authorize the assisting physician to provide Avianca
with all information required by its medical department in order to confirm that my health condition is suitable for air travel in a pressurized cabin,
and therefore, I waive medical confidentiality. I agree to bear all expenses arising from such special assistance in case my health condition worsens,
and I hereby agree to release the carrier, its employees, and outsourced service providers and agents from any liability therefor. I further agree to
reimburse the airline for any extraordinary expenses arising from my travel.
Place:
F-GHU-085-02_vs1
Date:
21/07/2015
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Passenger's Signature:
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Oceanair Linhas Aéreas S/A
MEDIF
Medical Information Form for Special Assistance Passengers
IATA - Resolution 700 (Schedule B) – Part 1
CONFIDENTIAL
To be completed by the authorized physician. Answer ALL questions.
Please PRINT or TYPE. Answer with accuracy.
1. Full name:
Date of Birthday:
/
/
Gender
Male
Female
Height:
Contact: Passenger’s phone #
Weight:
E-mail:
2. Authorized physician:
E-mail:
Physician ID
Phone (cell phone / country and area code):
Fax (country and area code):
Telefone do consultório:
3. Primary Diagnosis and Associated Pathologies: (including date of illness onset, episode or accident and treatment; specify if
contagious):
Fractures?
Yes
No // Type of Treatment:
conservative / immobilization //
Nature and date of any recent surgery (regardless of its size:
Carrier of Contagious and Infectious Disease?
Yes
surgery
Date surgery:
/
/
No Especifique:
4. Current signs and symptoms. (Inform severity - vital signs required):
Is the disease:
Cured?
Stable or controlled?
Yes
Yes
No
No
Complication-free (surgery) recovery?
Yes
No
Prognosis to travel?
5.
Good
Regular
Bad
Will a 25% to 30% reduction in ambient partial pressure of oxygen (relative hypoxia) affect patient's medical condition? (Cabin
pressure will be equivalent to a fast trip to a mountain with an elevation of 8,000 feet (2400 meters) above sea level)
Yes
No
6. Additional clinical information:
a. Anemia
Yes
No
If yes, forward recent hemoglobin results:
b. Psychiatric disorder / seizures
Yes
No
If yes, see part 2.
c. Cardiovascular disease
Yes
No
If yes, see part 2.
d. Normal bladder control
Yes
No
If not, state control method:
e. Normal bowel control
Yes
No
f.
Does the passenger undergo
dialysis?
g. Respiratory disease
Yes
No
Se Yes, qual o tipo?
Yes
No
If yes, see part 2.
h. Does the passenger use oxygen at
concentrator
at home?
home
?
Yes
No
Se Yes,
Contínuo
Intermitente
LPM.
Additonal Information:
If yes, what actions were taken to provide oxygen within the airport(s) (Boarding / Connections / Disembarking)?
i.
Oxygen needed in-flight?
Continuous flow?
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21/07/2015
Yes
No
Yes
No
If yes, specify (from 2 LPM to 8 LPM)
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LPM.
Oceanair Linhas Aéreas S/A
MEDIF
Medical Information Form for Special Assistance Passengers
7. Escort:
a. Is the patient fit to travel unaccompanied?
Yes
No
b. If no, would a staff member or assistant (provided by the airline when boarding and disembarking) be sufficient?
Yes
No
c. If no, will the patient have a private escort to take care of his/her personal hygiene and feeding needs onboard?
Yes
No
d. If yes, who should escort the patient?
Médico
Enfermeiro
Outro
e. If other, is the escort fully trained to attend to all the needs above?
Yes
No
8. Mobility:
a. Capaz de deambular sem ajuda ou assistência?
b. Wheelchair required for boarding?
If Yes,
YesYes No No
c. Is the patient able to use aircraft seat in VERTICAL position if necessary?
Yes
No
d. Can passenger bend leg at the knee ?
Yes
No
e. Can passenger bend leg at the hip?
Yes
No
f.
Yes
No
g. Can passenger support his/her head while taking off and landing?
Yes
No
h. Can passenger support his/her upper body on the seat?
Yes
No
i.
Stretcher needed on board?
to aircraft //
Does passenger need additional supporting equipment such as belts, neck braces, among others?
to seat
Yes
No
Specify:
9. List of current medication:
Does passenger need any medication to be handled by another person in the airport or during the flight?
Specify:
Yes
No
10. Other medical information:
Hospitalization? Date of admission:
/
/
Date of discharge
Does passenger need hospitalization after boarding? Yes
During long delays or overnights during the itinerary? Yes
No
/
/
Hospital
Specify:
No
Other information or suggestion that may provide the passenger with an easier and more comfortable transportation:
Specify:
Nota: The attendants are not authorized to provide special care to a specific passenger, to the detriment of other passengers. Additionally, they are
trained on First Aid procedures only, and they are not allowed to give injections or administer any drugs to passengers.
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Oceanair Linhas Aéreas S/A
MEDIF
Medical Information Form for Special Assistance Passengers
IATA - Resolution 700 (Schedule B) – Part 2
CONFIDENTIAL
To be completed by the authorized physician. Answer ALL questions. Please PRINT or TYPE. Answer with accuracy.
1. Cardiovascular Disease:
A. Angina

Is he/she currently stable?

Patient's functional rating:
No symptoms //

Yes
No
Yes
No
Date of last event:
Angina with strenuous exertion //
/
/
Angina with strenuous exertion //
Angina when resting
Can the patient walk 100 meters at a normal pace or climb 10-12 stairs without symptoms?
B. Myocardial infarction
Yes
No
Date:
/
Yes
No
/

Complications?
Yes
No
If Yes, provide details:

Cardiac stress test?
Yes
No
If Yes, inform the results:

the patient underwent angioplasty or coronary bypass surgery, can he/she walk 100 meters at a normal pace or climb
10-12 stairs without symptoms?
Yes
No
C. Heart failure
Yes

Is the condition controlled with medication?

Patient's functional rating:
No symptoms
Shortness of breath with light exertion
breath when resting no repouso
 Investigations?
2. Chronic lung disease?
No
Date of last event:
Yes
/
No
Shortness of breath with strenuous exertion
Shortness of breath when resting
Yes
No
Yes
No
a.
Has the patient had a recent arterial gas analysis?
b.
Blood gases taken under:
If Yes, inform the results:
Yes
Ambient Air
No
Oxygen
If yes, inform the results:
pCO2
Yes
/
LPM
pO2
Saturation Exam date:
/
c.
Does the patient retain CO2?
d.
Has the patient had a recent deterioration in lung condition?
Yes
No
e.
Can the patient walk 100 meters at a normal pace or climb 10-12 stairs without symptoms?
Yes
No
f.
Has the patient ever travelled in a commercial aircraft under the same conditions?
Yes
No


If yes, when? Date:
/
/
Has the patient shown any problem? If Yes, which?
3. Psychiatric disorder?
Yes
No
No
a.
Is there a possibility that the patient will become agitated during flight?
Yes
No
b.
Has the patient ever travelled in a commercial aircraft before?
Yes
No

If Yes, when?
/
/
The patient traveled
4. Seizures?
Yes
a.
What kind of seizures?
b.
Frequency of seizures?
c.
Date of last seizure:
/
Good
Alone
Escorted
No
/
Are seizures controlled by medication?
5. Prognosis to travel
/
Yes
Regular
No Which?:
Bad
Physician's signature and stamp:
Date:
/
/
Note 1: The crew is not authorized to provide any special care (e.g., carry / lift) to a specific passenger in detriment of servicing other passengers.
Additionally, the crew is trained on First Aid procedures only, and is not authorized to administer any drugs to passengers.
Note 2: In case the passenger is admitted, this information will allow for the necessary actions for his/her safety and comfort to be taken.
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Oceanair Linhas Aéreas S/A
MEDIF
Medical Information Form for Special Assistance Passengers
INFORMATION TO GUIDE THE ASSISTING PHYSICIAN OR AUTHORIZED ESCORT
The purpose of all information supplied by the airline physicians is to inform the situation within a pressurized cabin. The main
factors to consider when assessing the qualification of a patient for air transportation are atmospheric air pressure variations
(expansion and contraction of gases may cause pain and pressure effects). During flight there is a resulting reduction in
oxygen tension (equivalent to an altitude of 8,000 feet, and a partial oxygen pressure approx. 20% lower than ground
pressure).
The following conditions are considered UNACCEPTABLE for air travel.
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Severe anemia.
Acute, infectious, contagious diseases or diseases of compulsory notification.
Congestive Cardiac Failure or other cyanotic conditions nor fully controlled.
Acute Myocardial Infarction with less than six (6) weeks of onset.
Severe respiratory disease or recent pneumothorax.
Gastrointestinal lesions which may cause hematemesis, melena or intestinal obstruction.
Recent post-operative cases - Including plastic surgery: Within ten (10) days for simple abdominal operations, within
fourteen (14) days for chest surgeries, and within seven (7) days for invasive eye surgery (except laser).
Unstable mental illness unescorted by a physician and not carrying adequate in-flight medication.
Uncontrolled seizures (unless escorted by physician).
Mandibular fracture with fixation (except if escorted by physician).
Injection of air to body cavities for diagnostic or therapeutic purposes within five (5) days.
Pregnancies beyond 36 weeks or multiple pregnancies beyond 32 weeks.
Infants within seven (7) days of birth.
Acute otitis and sinusitis cases.
Other health issues that may also be observed
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Allergies: You must complete the MEDIF form if your patient has a lethal food allergy that may require in-flight treatment.
OceanAir Linhas Aéreas S/A (Avianca) cannot ensure the supply of allergen-free food.
Asthma: Medicine typically used must be carried in your hand luggage. Nebulizers must have own power sources.
Fractures: The MEDIF form must be completed in all cases. Casts immobilizations must be put at least 48 hours before the
passenger's flight begins. Passengers with full leg casts cannot be properly placed in regular seats within the airplane, and there
is no extra legroom for immobilized leg elevation. In this case, a stretcher may be deemed necessary as assessed by Avianca's
medical team.
In case of recent fractures – with less than 48 hours – the fractured member may swell during the flight, leading to potential
vascular complications. In this case, the assisting physician must decide whether it is necessary to open the cast, preventing
further complications; and this condition is required for the boarding authorization. Large bone fractures can lead to anemia.
Boarding of passengers with HGB below 9.5 g/dl shall be denied.
Lung or Heart Disease: Cardiopulmonary disease which causes dyspnea with medium exertion, or which requires oxygen in the
hospital, or on previous flights, may require supplementary oxygen. The aircraft oxygen is for emergency use only.
In case supplementary oxygen and/or stretcher transportation are needed, in addition to the MEDIF completion, a recent* and
detailed copy of the passenger's medical records must be supplied (in case of supplementary oxygen, please include: O 2
saturation in ambient air and recent Hb).
Terminal Illness: Passengers in advanced stages of terminal illnesses will normally require a physician or nursing escort.
General
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The MEDIF must be completed based on patient's physical conditions within fourteen (14) days from the date of the flight. (THIS
DOES NOT APPLY TO PREGNANT WOMEN).
In-flight care: Cabin crew members are trained in First Aid only; therefore, we do not provide nurse attendants for passengers
who need special assistance.
Escorts: Escorts should ensure that they have all appropriate items for the proper care of their patient, and that they are
responsible for attending to all aspects of the patient's physical needs. Due to regulations on food handling, and others, the crew
cannot attend to such needs.
Civil aviation authorities issue guidelines for physicians to assess whether the patients are suitable for air travel. The
assessment made by the relevant medical department is based on such guidelines .
I hereby declare I have read and understood the MEDIF Form.
The listing above is neither final nor exclusive, and each case shall be clinically assessed on an individual basis according
to the circumstances.
Physician's signature and stamp: ________________________________ Place: _________________________________ Date:
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Oceanair Linhas Aéreas S/A