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1、诊断证明书诊断证明书Certificate of DiagnosisCertificate of Diagnosis1 1 旅客姓名旅客姓名 Name of PassengerName of Passenger：2 2 年龄年龄 AgeAge：3 3 性性别别 SexSex：4 4地址及联系方式地址及联系方式 Add.and contactAdd.and contact：5 5 航程航程 RoutingRouting：航班号航班号 Flight No.HUFlight No.HU日期日期 DateDate月月 MonthMonth日日 DayDay自自 FromFrom至至 toto联程联程
2、ViaVia：航班号：航班号 FlightFlight No.No.日期日期 DateDate月月 MonthMonth日日 DayDay自自FromFrom至至 toto6 6诊断结果诊断结果 Result of diagnosisResult of diagnosis：7 7 症状、症状、程序、程序、预后预后（如系孕妇需注明预产期）（如系孕妇需注明预产期）Symptom,process,prognosis(indicate expected date of childbirth,if pregnantSymptom,process,prognosis(indicate expected d
3、ate of childbirth,if pregnantwoman)woman)：注注（1 1）上述第）上述第6 6、7 7 两项内容填写，需简单、明确。两项内容填写，需简单、明确。（2 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）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。提供必要的服务时作为参考。Note(1)The above describedNote(1)The above described 6 6 and 7 items shalland 7 items shall be filledbe filled shortly a
4、ndshortly and clearly.clearly.(2)(2)TheThe contentcontentdescribed in the form under is for reference to cabin crew who offer necessary service to sick or injured passengers during flight.described in the form under is for reference to cabin crew who offer necessary service to sick or injured passen
5、gers during flight.程度程度 DegreeDegree无无 NormalNormal轻度轻度 MildMild中等中等 ModerateModerate严重严重 SevereSevere备注备注 RemarkRemark症状症状 SymptomSymptom贫血贫血 AnemiaAnemia呼吸困难呼吸困难 DyspneaDyspnea疼痛疼痛 PainPain血压血压 Blood PressureBlood Pressure8 8附注：附注：（如有膀胱、直肠障碍或者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）（如有膀胱、直肠障碍或者者在飞行中需要特殊餐食及药物医
6、疗处理情况等，请予以列明）PS:(If suffering fromPS:(If suffering frombladder and recta,or needing special food and medical treatment on the flight,please list it clear)bladder and recta,or needing special food and medical treatment on the flight,please list it clear)9 9需要何种坐姿（将下列适用的项目用需要何种坐姿（将下列适用的项目用 圈起）圈起）Which
7、 kind of seating position is needed(Enclose the following applicableWhich kind of seating position is needed(Enclose the following applicableitems with)items with)：1 1使用机上通常座椅使用机上通常座椅 Taking common seatTaking common seat2 2使用机上担架设备使用机上担架设备 UsingUsing乘坐姿态乘坐姿态 Seating PositionSeating Positionsupportin
8、g equipmentsupporting equipment医生医生 Doctor Doctor 护士护士 Nurse Nurse 其他人员（具体列明）其他人员（具体列明）Others(list in details)Others(list in details)不需不需陪伴人员陪伴人员 AttendanceAttendance要要 No needNo need轮椅轮椅 WheelchairWheelchair要要NeedNeed不要不要No NeedNo Need上下飞机时上下飞机时 Deplane orDeplane orenplaneenplane担架担架 StretcherStret
9、cher要要NeedNeed不要不要No NeedNo Need救护车救护车 AmbulanceAmbulance要要NeedNeed不要不要No NeedNo Need已参阅下面的资料，我院诊断认为：该旅客的健康条件在医学上能够习惯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 therequirements of air travel,he/she hasnt communi
10、cable disease,and doesnt influence other passengers.医师（签字）医师（签字）PhysicianPhysician(signature)(signature)：电话电话 TelTel：医疗单位（盖章）医疗单位（盖章）MedicalMedicalUnit(seal)Unit(seal)日日 期期（年年 月月 日日）Date(Y./M/D)Date(Y./M/D)：参考资料参考资料（下述内容仅供医生在推断病人是否适于航空旅行时的参考）ReferencesReferences(The following contents are only for p
11、hysiciansreference on the fact whether a patient is suitable for air travel or not)一、机上条件一、机上条件 I.Conditions on boardI.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 atmosphe
12、ric conditionsat 2300 meter(7000 ft),which cause expansion 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通常的急救训练，但不同意为病人注射。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，无暇更多地特别照看病人。The cabin crew are only trained for common first aid,a
13、nd not allowed for patient injection.And that,the cabin crew should be responsible for service during flight,so they have no time to especially attend patients more.4机舱内的活动范围与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 techniqueand equipment in cabin.二、二、处于下述状况的病人，处于下述状况的病人
14、，通常不适于航空旅行通常不适于航空旅行 II.The people,who is in the following conditions,isnt suitable for air travelII.The people,who is in the following conditions,isnt suitable for air travel：1处于极严重或者者危急状态的心脏病患者。如严重的心力衰竭，出现紫绀症状或者者心肌梗塞者（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.sever
15、e heart failure,cyanosis,or myocardial infarction(Thecase of myocardial infarction occurred within six weeks before traveling)2出生不满 14 天的婴儿。Infant under 14-day age3 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 w
16、oman,whose pregnancy is more than 32 weeks but notexceeding 36 weeks,wants to take airplane,it requires her to offer a physicians signed certificate of diagnosis dated within 72-hourbefore departure.)4血色素量在 50%（Hb8g.dl）下列的贫血病人。The patient suffering from anemia with hematochrome level below 50%(Hb 8.
17、0g.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 tubes6近期患自发性气胸的病人或者者近期做过气脑造影的神经系统病症的患者。The patient suffering from spontaneouspneumothorax 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
18、颌骨骨折最近使用金属线连接者。The patientsuffering 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 酒精或者者其他毒品中毒者；患有精神病，易于伤人或者者自伤行为者。Alcoholism or drug addiction;psychotic,aggressivebeha
19、vior or autolesionism.9 近期进行过外科手术，伤口未完全愈合者与产妇产后不满二周者。Having a surgery recently,the wound hasnt been healed upcompletely;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。The patient has been suffering from poliomyelitic or bulbarpoliomyelitis within last 3
20、0 days.11下列传染病或者者疑难病患者：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 following infectious disease or complicated disease cholera,typhoid fever,paratyphoid fever,typhus,dysentery,smallpox,scarlatina,diphtheria,plague,epidemic encephalitis,meningitis,pulmonaryt
21、uberculosis and other infectious diseases.12带有传染性或者者损伤、使其他旅客感到厌恶的皮肤病患者。The patient suffering from infective or traumatic dermatosis,which make other passengers feel sick.13 带有严重咯血、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，
22、交始发站值机部门留存；第三联为到达联，交到达站本单为一式三联：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。服务部门留存。ThisThis formform is is inin triplicate:triplicate:thethe firstfirst sheetsheet is is forfor issuing,issuing,keptkept byby issuingissuing unit;unit;thethe secondsecond sheetsheet is is forfor flight,flight,ke
23、ptkept byby check-incheck-indepartment of airport of departure;the third sheet is for arriving,kept by the service department of airport of destination.department of airport of departure;the third sheet is for arriving,kept by the service department of airport of destination.注：注：13-413-4附表应以中英文结合印刷并
24、交付现场使用，建议使用附表应以中英文结合印刷并交付现场使用，建议使用ISOISO标准标准A4A4型纸（尺寸：型纸（尺寸：210210297mm297mm）。Note:Attached Form 13-4 should be printed in Chinese and English for use on site.We suggest that the paperNote:Attached Form 13-4 should be printed in Chinese and English for use on site.We suggest that the papershould adopt A4 Type of ISO standard(Size:210should adopt A4 Type of ISO standard(Size:210297mm)297mm)