MEDICAL CLEARANCE FORM (MEDA)
This form is intended to provide CONFIDENTIAL information to enable the airline’s MEDICAL
Department to assess the fitness of the passenger to travel. If the passenger is acceptable for air travel, thisinformation will permit the issuance of the necessary directives designed to provide for the passenger’s
welfare and comfort. The PHYSICIAN ATTENDING of the passenger is requested to ANSWER ALL
QUESTIONS in ENGLISH or TRADITIONAL CHINESE.
Enter a Check “¨ in the appropriate boxes, and / or give precise concise answers.
PASSENGER’S Name(as appears on your passport)
MEDA 01

Gender□ Male □ Female

AgeFlight No.

Travel Date (DD/MM/YYYY)□ Wheelchair □ Stretcher □ Others __________For Doctor Use Only
ATTENDING PHYSICIAN’S Name

Weight_____Kg (For stretcher case)

Phone Number

MEDA 02
Hospital Clinic Affiliation (Official Stamp)
Is passenger PREGNANT? □ No, (Please skip MEDA03) □ Yes
GA：________weeks + _________day(s)EDD (DD/MM/YYYY)：_____/_____/_____

Gestation：□ Single □ Multiple
MEDA03
Have passenger had any pregnancy complications?
□ No (Please skip MEDA04)□ Yes, (□ Eclampsia □ Preeclampsia □ Gestational Diabetes □ Gestational hypertension□ Anemia □ Others ___________.) If yes, please fill in MEDA04.
DIAGNOSIS in details

Date of diagnosis (DD/MM/YYYY)

Date of first symptoms (DD/MM/YYYY)

MEDA 04 1.

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Date of Operation (DD/MM/YYYY)

GCS_______ (Pregnant women may skip this item)

2.

SpO2___% (room air) or SpO2___% or on O2 _ L/min via _________________ (Pregnant
women may skip this item)3.

BP______；RR______； HR______；Temp______°C； Hb ______ g/dL

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Summary of medical records attached【operation or admission□ No □ Yes

within 2 weeks】
MEDA 05 Fitness for the Flight(s) ?

□ Fit to Travel□ Not Fit to Travel, Specify：___________MEDA 06 Contagious AND Communicable Disease? Specify if YES：

□ No □ Yes

Would the physical and／or mental condition of the patient be likely toMEDA 07 cause distress or discomfort to other passengers or one’s self ?
Specify if YES ____________________________□ No □ Yes

Can passenger use normal aircraft seat with seatback placed in
the UPRIGHT position when required ?

□ No □ Yes

MEDA 08

Can passenger understand and respond to cabin crew’s safety instructions andassist one’s own evacuation in the event of emergency?
Q1. If not, the passenger must be escorted.
MEDA 09 Q2. Can passenger take care of his own needs on board UNASSISTED【including meals, visit to toilet, administer medications, etc.】?
If not, the passenger must be escorted.
Q1. Does the passenger require an ESCORT?
Q2. If to be ESCORTED is the arrangement satisfactory to you?
MEDA 10□ No □ Yes□ No □ Yes□ No □ Yes□ No □ Yes

Type of escort proposed by YOU：
□ Travel companion □ Nurse □ Doctor □ Nurse & Doctor□ No □ Yes

Does passenger need OXYGEN?
Period of usage□ On Ground□ During Flight

MEDA 11 Oxygen flow rate □ 2 L/MIN □ 4 L/MINContinuous□ No □ Yes□ 2 L/MIN □ 4 L/MIN□ No □ Yes.

Estimated amount of OXYGEN：_____________BT

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Does passenger need any MEDICAL DEVICES** such as portable oxygen
concentrator (POC) , CPAP, suction, infusion pump, ventilator?
MEDA 12□ No □ Yes

If yes, please see note and specify.
1.

The brand and type of medical device：2.

Size： Width ____________ Depth ____________ Height ____________【□ Centimeter / □ Inches】
Period of usage □ On GroundContinuous□ During Flight□ No □ Yes□ No □ Yes

Can passenger use the medical device(s) unassisted?
Does passenger need any MEDICATION, other than self-administered?
MEDA 13 Specify if YES：

□ No □ Yes□ No □ Yes□ No □ Yes

Can it be administered by the escort?
Does passenger need HOSPITALISATION during transit/transfer
MEDA 14 at CONNECTING POINTS?

□ No □ Yes

If yes, indicate arrangements made：MEDA 15

Does passenger need HOSPITALISATION upon ARRIVAL?
If yes, indicate arrangements made：□ No □ Yes

Other remarks, information and arrangements madeMEDA 16Attending Physician's Signature

License/Provider Number

Consent SignatureDate(DD/MM/YYYY)

Date(DD/MM/YYYY)

Declaration
1.

For the purpose of medical clearance, China Airlines Ltd. ("CAL" or "we") will collect, process, use,transmit (including international transmission) and disclose your Personal Data (hereinafter collectively
referred to as "Personal Data"), pursuant to Personal Data Protection Act ("Act"), CAL's Privacy
Protection Policy and other applicable laws/regulations, we hereby notify you the following.
(1) The above personal medical data (Medical Clearance Form, Certificate of Diagnosis., Medicalsummary) and personal information about the attending physician (Full name, License/Provider
Number, Phone number) are agreed by you to be utilized for China airlines' handling after you sign
this MEDICAL CLEARANCE FORM. Please visit CI official website (Privacy Protection) for
additional information.

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(2) You are in the position to decide whether to provide the related Personal Data. However, if you
decide to provide Personal data, CAL may not be able to engage in necessary business orprocessing and will not be able to provide relevant to you. Your understanding is appreciated.
(3) In accordance with Article 3 of the Act and other applicable laws/regulations, you or the protectednatural person (as applicable) may exercise following rights with respect to your Personal Dataretained by CAL:
(4) Except the situation stated in Article 10 of the Act and other applicable laws/regulations, you may:i.
Inquire or review Personal Data, but CAL may charge reasonable fees;ii.
Make duplications of Personal Data, but CAL may charge reasonable fees;iii.
Supplement or correct Personal Data, but shall with proper explanation;
iv.
Terminate the collection, processing or use Personal Data, to the extent that such Personal
Data is not necessary for CAL to conduct business, contractual agreement or fulfillment of alegal obligation;v.
Restrict of precessing Personal Data, but it does not prevent CAL to store your Personal Data;vi.
Restrict of automated individual decision making;vii.
Request to delete Personal Data, to the extent that such Personal Data is not necessary for CAL
to conduct business or CAL is otherwise legally entitled to retain same;viii.
Request for data portability;ix.
Opt-out or unsubscribe from marketing.
Cabin crew are NOT authorized to give special assistance to passengers such as personal care and lifting.
Additionally, they are trained only in FIRST AID and are NOT PERMITTED to administer any
injection or give medication.
With the medical assessment of the ATTENDING PHYSICIAN, the undersigned (Passenger, or parentor guardian of the above-named passenger), is fully aware of China Airlines’ transport terms andconditions when submitting this Medical Clearance Form and will hold China Airlines, its board ofdirectors, officers, agents, or employed personnel harmless from and against any and all liability, loss,expense (including attorneys’ fees), and claims for injury or damages arising out of the performance of
this transportation.
The undersigned (ATTENDING PHYSICIAN) shall, based on the medical profession, faithfully provide
the information of this Medical Clearance Form and attachment(s) of the related diagnosis
documentation; otherwise, the undersigned shall be held responsible for the Criminal Code of forgery
and administrative liabilities shall be imposed for violation of Physicians Act.
The medical clearance form and related medical documents must be submitted in FULL for approval 2
working days prior to departure (weekends are not included).

Notes for carrying medical equipment on board
1. For the brand and the model of the medical equipment, please refer to the China Airlines On Board
Medical Equipment Table (verified through RTCA-Requirement and Technical Concepts for Aviation),and the device must have the manufacturer‘s trademark for the CI staff identification. In addition to themodels listed in the table, other POCs that have a label indicating "RTCA/DO-160~ Section 21 Category
M Compliant FAA Approved" or "The manufacturer of this POC has determined this device conforms toall applicable FAA acceptance criteria for POC carriage and use on board aircraft." will be accepted to becarried and used on board.
2. Charging equipment is not permitted on board, spare batteries must be brought on board following China
Airline’s regulations. Additionally, they must meet the provisions in the Dangerous Good Regulations ofAir Transport.

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For Airport Staff use onlyPhysical or mental conditions declaration by passenger : _______________________________________________________________________________________________________________________________
Passenger is pregnant and the duration of pregnancy is _________ weeks. Passenger assures her physicalcondition is suitable for the flight.
Passenger is sick and needs special assistance. Passenger assures his/her physical condition is suitable forthe flight.
Other conditions: __________________________________________________________.
 I hereby acknowledge that I have completely read and fully understand and I have honestly reported myphysical and mental conditions to China Airlines and Gate Screen.
The Undersigned Name : _____________________Relation to passenger : _________________
Signed by the Undersigned (Passenger / Parent / Guardian) : ________________________

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