Guidance for filling out Medical Information Form
Transport by aircraft has comparatively advantages in smoothness, with less vibration and motion. It is, in most cases,
the quickest and convenient way. However, long flight time and pressure change caused by changing flight altitude
may sometimes adversely affect passenger’s (patient’s) medical condition. For these reasons, air travel may not besuitable for all passenger (patients).
Aircraft fly at an altitude of 9,000-12,000 meters (30,0000-40,000 feet) through the stratosphere at almost the speed ofsound, 900km per hour (560 miles per hour). At high altitude and where barometric pressure is much lower than onground, aircraft cabin is mechanically pressurized during the flight. The cabin air pressure during the cruise ismaintained at equivalent to that of 1,500-2,100 meters (5,000-7,000 feet).
♦ Air pressure
The cabin air pressure drops oxygen density to 70-80 % of that on ground. The pressure changes greatly during 15-30
minutes after takeoff and before landings. Aerotitis and stomachache of enteron are caused by change of air pressure
in a short time.
♦ Decrease in oxygen density
Person having problems with respiratory disorders, cardiac disorders, cerebrovascular disordersl and severe anemia
are all affected by decreasing oxygen density at high altitudes.
For the above reasons, in order to assess the fitness of passenger (patient) for air travel, person travelling with any of
the following conditions will be requested to prepare a medical certificate and submit when making reservation.
(1) Person whose medical condition requires Oxygen supply (inhalation), carriage and/or use of medical equipment
and/or instruments, and any treatment in flight.
(2) Person with serious sickness or injuries.
(3) Person who comes under any one of the categories listed on the next following page.
(4) Other than above, you are required to submit a medical certificate in the case of injury and disease under
treatment and recent surgical procedures that may affect your condition during air travel.
A credible medical certificate for an air travel must be issued within 14 days, including the day of departure.
However, passengers with diseases that may cause sudden changes in their physical condition, such as heart,
respiratory organs, cranial nerves, or neuropsychiatric diseases and pregnants whose estimated delivery date is within
28days from departure date need to prepare this form that is made within 7days from the start day of journey.
Please consult us about arrangement for reservation that above day before. If the adverse change of the passenger’s(patient’s) medical condition is observed, we shall ask the passenger (patient) to submit a new medical certificate toreconfirm the fitness for air travel.
Forpassengers
For attending
physician： Please complete “Necessary Arrangement Request”, including your signature on the “Agreement”
box.
： Please complete “MEDIF”, the fourth page of this form. Please determine the fitness of thepassenger (patient) for the purpose of air travel by taking the whole itinerary into consideration.
We would also appreciate any comments about current condition and suggestion for the proposed
travel in the lower remarks space of “MEDIF”.

Guidance for Physicians and Passengers
Person who are legal epidemic, specified epidemic and suffering and/or suspected of having
any infections or/and contagious disease shall not be accepts for air travel.

Persons under the following conditions are generally considered unfit for air travel. However, if the medical conditions or thestate of health of the person is considered stable and the physician certifies the person as “Fit to Air Travel” with theprognosis, passenger can be accepted for air travel, then please consult with our reservation representative for further
information.

1.

Those who have critical cardiac：

disease, severe heart diseases

Cardiac failure, cyanotic heart disease conditions, angina pectoris, acute
myocardial infarction (Person who have had such disease within past six
weeks are not acceptable for air travel.)

2.

Those who have severe：

respiratory illness
3.

Severe respiratory failure, severe chronic obstructive pulmonary disease, orrecent onset pneumothorax with an incompletely inflated lungThose who have repeatedhemoptysis

4.

Those who have acute phase ofstroke：(Personwho have had this diseasewithin past 4 weeks are not acceptable for
air travel.)

5.

Those who have air remaining in central nervous system after examination or cranial surgery

6.

Those who have head injury with increased intracranial pressure, fracture of the skull, or those who underwent
permanent wiring in the jaws for mandibular fracture

7.

Those who have severe anemia

8.

Those who may cause hematemesis, or melena, Bowel obstruction patients

9.

Those who have severe otitis
media

10.

Those who have not completely recovered from injury (such as surgery of head, chest or abdomen)

11.

Those who have mental nerve disease and alcoholism or drug addiction

12.

Newborn baby within the first 7days of birth13.

Pregnant woman whose expected delivery date within 28 days (if obstetrician certifies the fitness for air travel, aescort by a physician is not required.) However an escort by a physician shall be required if travelling by aircraft within
14 days of the expected delivery date for international flights and 7 days for domestic flights.

Please consult us about patient’s medical transport separately.

Necessary Arrangement Request (Please kindly fill in below.)(Itinerary) Flight Information
Flight No.

Month:

Day:

Section:From

To

Flight No.

Month:

Day:

Section:From

To

Flight No.

Month:

Day:

Section:FromTo□service at the airport?

No□

If “Yes”, how far can you walk without a wheelchair? There are three categories.
□ Can walk alone in cabin and can ascend or descend stairs by myself but cannot walk longdistance.
□ Can walk alone in cabin, but cannot ascend or descend stairs by myself.
□ Cannot walk by myself.

Yes

1. Do you require a wheelchair

2. Are you travelling with your own wheelchair?

□Yes
□No
□ Manual wheelchair□ Power driven wheelchair*1
Please note that the power driven wheelchair shall be checked visually at the airport. If it is difficult tocheck the battery, we recommend that you bring an instruction manual.

□ Non-spillable□ Spillable□ Dry Battery(□Lithium ion(Li-ion), □ Nickel cadmium(Ni-Cd), □ Nickel hydrogen(Ni-MH))*The number of spare Lithium ion batteries which can be carried on board is restricted to one sparebattery no greater than 300wh or maximum of two spare batteries no greater than 160wh each.
Spare Lithium ion battery□I have （How many:）□I do not have

Wheelchair Type□ Collapsible□ Non-collapsible
If Non-collapsible, or Power driven wheelchair please describe the size below.
cm) ・ Depth(Width(3. Do you need wheelchair in cabin?

□Yes(When use of lavatory facilities etc.)□Nocm) ・ Height(cm) ・ Weight(kg )4. Personal Escort (a physician, a nurse, or a person approved by a physician)*Need personal escort, if you are diagnosed by doctor.
NameAge

1□Physician□Nurse□A person approved by a physician

2□Physician□Nurse□A person approved by a physician

Agreement
I hereby agree that(Name of Hospital and Attending physician) shall provide the relevant airlines with the information

the airline requires to decide whether my health condition is fit for air travel.
In addition, I agree that I shall pay the expenses related to the attending physician and costs incurred by my carriage, and also that I shall exempt the physician’s
professional duty of confidentiality to the extent of the information concerned.
I shall confirm that, if the airline accept my carriage, the carrier does not assume any special liability beyond Conditions of Carriage / Regulations for the carriage
concerned.
Address：

Date：

Passenger
Signature：

Document Handling ：(or a Representative)

Note that Necessary Arrangement Request and Medical Information Form shall be attached to the air tickets.
Copy the number of sheets for the boarding section and attach this to the air tickets.

(Internal)

When handling boarding procedures in each section, hand out one copy to the cabin crew and keep one upon arrival of the destination.

MEDICAL INFORMATION FORM（MEDIF）

To be completed by attending physician

The attending physician is requested to answer all questions below.
For “Yes” or “No”, please kindly Enter a mark (✔) in the appropriate box, and give us your precise and necessary description required for air travel.

<Notes>

1. As for No. 3 and No. 4, please kindly write the name of the disease and symptoms so that anyone other than a physician can understand.
2. Flight attendants are fully trained in FIRST AID, but medical care such as injections, administration of medications, and operation of Medical OxygenCylinders are not permitted. Additionally, please understand that they cannot take care of sick passengers or specific passengers at all time because of
their in-flight service to other passengers.
3. We shall request additional charges for securing seats for installing and arranging medical instruments.
Passenger

No.01(Patient)
PhysicianNo.02

InitialName：

Diagnosis (Disease Name)：<Note 1>

Date of First Symptoms (Date of Operation)：<Note 1>

Hospital name：Date of Diagnosis：

Progress (Prognosis) for the flight(s) and fitness of air travel
for the patient(Please also consider the potential effect of itinerary on thepatient’s state of health.)□Fit

Not FitContagious and/or communicable disease?

No

No.06

No.07

No.08

Would the physical and/or mental condition of the patient belikely to cause distress or discomfort to other passengers?

Whether he/she can sit upright with seat belt fastened
during take-off, landing and the time required.

Can the patient take care by yourself without any assistance.
(Use of lavatory facilities, eating and drinking etc.)

Yes
No
Yes
No
Yes
No
Yes

No09

Profession：

Symptom：

Yes

No.05

Can the patient travel alone?

No□□
□
□□□
□
□
□
□
□

If “Not Fit to Travel”, please specify:

Prognosis for the Return Flight (ifany)(Date of Return Flight)[ Month/Date:]

Yes

Does the patient need to inhale oxygen in flight?

No□□

Not FitIf “Yes”, please specify:

If “No”, please specify the necessary assistance.

If “No”, does the patient need physician/nurse/ a person who isapproved by physician?

Liters per minute[□

Yes

Does the patient need any medication on board of aircraft?

No<Note 2>
Does the patient need any medical equipment in flightsuch as respirator or infant incubator etc. on board ofaircraft?

No. 12Yes

Does the patient need power source for that in flight onboard of aircraft?

YesNo
YesNo□□□□□□

If “Yes”, please specify.

If “Yes”, please specify.

If “Yes”, please specify.

Other remarks or information in the interest of your patient’s smooth and comfortable transportation.

No. 13
Other arrangements made by the attending physician:No. 14
We would appreciate any general comment about the patient’s condition suggestion for the proposed air travel.

Hospital name

Issuance Date□ℓ / minute ]※All electronic equipment must be verified it’s safety by the airline for onboard use. Please prepare the equipment incorporating battery.

Prognosis as above.

No②Can the patient or escort operate the Medical Oxygen Bottle?

Yes

No. 11□□Fit

If “Yes”, please specify:

If “Yes” ⇒ ①Continuous use?

No. 10Gender：Phone Number ( in case of emergency)：

No.03

No.04

Age：

Name:

Signature (Attending Physician)□No□