Information on Completing the Medical Certificate

For doctors and passengers

Long flight time and pressure change caused by changing flight altitude, may sometimes adversely affectpassenger’s medical condition. For these reason, air travel may not be suitable for all passengers.

Handling of Personal Information
Upon receipt of the MEDIF, ANA may contact customers if necessary.
Personal information is handled in accordance with the ANA Privacy Policy.

Cases when Medical Information Form (MEDIF) is requested
Person traveling with any of the following conditions are requested to notify our reservation staff and will be asked toprepare MEDIF when making a flight reservation.
①②③④⑤

Person requiring medical oxygen or medical equipment or medical treatments on board.
Person requiring a stretcher service or an incubator on board.
Person with serious diseases or injuries
Person who correspond to any of the categories listed on the next page.(GUIDANCE FOR THE PHYSICIAN)
Other than above. Person traveling by air may have adverse affects to one’s medical conditions due to recent
treatment or surgery.

Submitting MEDIF

For doctors and passengers

MEDIF must be prepared and issued within 14 days, including the day of departure. (Example: If the departure date isDecember 15, the MEDIF must be issued no earlier than December 2.) For round-trip flight, the date of return flight
may exceed 14 days if it states “Fit to travel” in the appropriate box of MEDIF. However, if adverse change of thepassenger’s medical condition is observed our staff may ask to submit a new MEDIF to reconfirm the fitness for airtravel.

Filling out MEDIF

For doctors

Please consider the travel and itinerary and their potential effects on the patient's state of health when writing theprognosis for whether the passenger is fit to fly. Please add any other matters of note should be considered in the'Specify more details, if necessary' field of the MEDIF.
For passengers whose condition or symptoms are stable, a period of validity can be included in their MEDIF. We ask
doctors to fill out the period of validity field in the MEDIF issued once a diagnosis has been made, following
consultation with the passenger (patient). The valid MEDIF must be carried on the passenger's person.

Fee or surcharge

For doctors and passengersFee if any, relevant to the provision of “Special Assistance Request” or MEDIF and for carrier-provided special
equipment are to be paid by the passenger concerned.
For following cases, the passenger must purchase extra seats.
*a stretcher service*extra seats for an incubator*an oversized medical equipment that cannot be stored under the seat in front
For flight safety reasons, some medical equipment may not be allowed in cabin or as checked baggage. Pleasecontact ANA Disability Desk (ADD) for specific regulation.

The cabin environment and effect on one’s bodyFor doctors and passengers

Aircraft cabin pressure is regulated by pressurization device at between 0.7-0.8 bars (10.2psia to 12psia), which equals
to that at an altitude of 2000-2500 meters However, significant changes in cabin pressure can occur 15-30 minutes
after takeoff and before landing.
As air pressure becomes lower in the cabin, normal internal gases present in the human body expand.

These

expanded gases not discharged from the body may put pressure on wounds or internal organs possibly cause pain or
breathing difficulties.
The cabin pressure drops oxygen density to 70-80% of that at sea level.
Respiratory organs, the heart, blood vessels in the brain and serious anemia can all be adversely affected by low
oxygen concentrations. Moreover, this may also affect women in late stages of pregnancy and newborn babies.

GUIDANCE FOR THE PHYSICIAN AND PASSENGER

For doctors and passengers

Passengers with Class 1, 2 or 3 infectious diseases, new types of influenza and other infectious
diseases, or new infectious diseases,Other serious acute infectious diseases that could betransmitted to other passengers by boarding the aircraftIn principle, passengers with serious
acute infectious diseases that could be transmitted to other passengers by boarding the aircraft
are not allowed to board.
Person’s condition which is not fit to travel❚A person who is prohibited from attending school by Japanese l aw(“Act on School Health and Safety”)
A p erson who is prohibited from attending school by Japanese law(*1) shall not be allowed to travel by air
unless a physician confirms that there is no risk of the disease to be transmit from person to person.
（*1）

The name of a disease

Period during which Attendance is ProhibitedCOVID-19

Until 5 days have passed after onset, and 1 day have passed after
become less severe.

Influenza

Until 5 days have passed after onset, and 2 days have passed after thetemperature has dropped

Whooping cough

Until the characteristic cough has suppressed, or until 5days treatment withantibiotics has ended.

Measles

3 days after his/her temperature has dropped

Mumps

After 5days of onset of the swelling on submandibular, sublingual andparotid gland, and major symptoms general condition recovered

Rubella
Chickenpox

Until eruption disappears
Until the eruption changes to scab

Pharyngoconjunctival

2 days after the main symptom disappears

Tuberculosis, Epidemic
keratoconjunctivitis, Acutehemorrhagic conjunctivitis

Until a physician evaluates that the disease becomes non-contageous.

❚Person with other symptoms or conditions
Persons with the following conditions are generally considered unfit for air travel. However, if aphysician certifies that the patient is stable, and that physician will be accompanying him/her on theentire journey, the airline may accept that individual for travel. Please contact ANA for furtherinformation.
1. Those who have critical cardiac disease, severe heart diseases such a cardiac failure, cyanotic heartdisease conditions, who have had an episode within the past 6 weeks are not acceptable for travel.
2. Those who have unstable angina pectoris, acute myocardial infarction, who have had an episodewithin the past 2 weeks are not acceptable for travel.
3. Those who have severe respiratory illness, server respiratory failure, severe chronic obstructive
pulmonary disease, or pneumothorax whose lungs are not fully inflated.
4. Those who have repeated hemoptysis
5. Those with apoplexy who have had an episode within the past 4 weeks are not acceptable for travel.
6. Those lesions resulted in 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 with lesions which may cause hematemesis, or melena, intestinal obstruction patients
9. Those who have severe otitis media
10. Those who have not completely recovered from surgery of head, chest or abdomen or women
immediately after childbirth
11. Alcoholism or drug addiction
12. Those who have residual air or other gas in his/her body after operation. (for example eye operation)
13. Pregnant woman whose confinement may be expected in less than 28 days. However an escort by aphysician will be required if traveling by aircraft within 14 days of the expected confinement forinternational flights and 7 days for domestic flights.
14. Newborn baby within the first 7 days of birth.
End
ADD01-013-240401

To be completed by the passenger or travel agent

SPECIAL ASSISTANCE REQUEST

Please answer ALL questions. Enter a cross (X) in the appropriate "yes" or "no" boxes.
Use BLOCK LETTERS when completing this form.
PATIENTS
AgeNameContact Info
Itinerary /Flight Info

TEL:

TEL:

Date:

Flight No.:

Travel Segment (DEP-ARR):(

－)

Date:

Flight No.:

Travel Segment (DEP-ARR):(－)

PhysicianEscort name

Nurse
Others ()PhysicianEscort name

Nurse
Others ()* Our cabin crew members can assist you in using the onboard wheelchair and stowing or retrieving carry-on items, identifying in-flight meal items, andopening packages. However, our cabin crew members are not permitted to provide medical services, assist with feeding or personal hygiene andlavatory functions. For those customers requiring such assistance, it is recommended to travel with an escort.
1

Wheelchair needed?

No
Yes→

Can not walk by myself
Can walk alone but can not ascend or descend stairs by myself
Can ascend or descend stairs by myself but can not walk long distance2

Wheelchair needed in cabin?

No

Yes

3

Please tell us about yourpersonal wheelchair.

No wheelchair* You can check your wheelchair at the counter. We will take you
to the plane in our wheelchair.

From Aug 10, 2012,
passengers will be allowed totransport spare Li-ion/Lithium-ion
batteries that power the mobilitydevice. If the battery is not fully
encased and protected to prevent
short circuit, the battery must be
removed and transported in thecabin of the aircraft. Please inform
us in advance for limitation may
apply.

ManualPersonal wheelchair

Electric/Battery-powered →Non-Spillable Battery (Wet-cell “sealed”)
Dry Battery *（□Li-ion/Lithium-ion □Ni-Cd □Ni-MH)* Please specify
FoldableNon-foldable →If your wheelchair is non-foldable or battery-powered, please tell us thesize and weight.
Depth

4

Spillable Battery (Wet-cell “non-sealed”)

cm

Widthcm

Heightcm
Weightkg*We may not be able to accept large-size wheelchairs due to the size ofthe cargo door and space.
Is Oxygen Cylinder neededin flght?

NoYes →

Personal medical oxygen cylinders
Oxygen Cylinder Rentals (Pay)* The passenger or escort should have knowledge in the use of oxygen cylinders.
Must be requested by reservation in advance.

5Stretcher needed on board?

6

Ambulance arranged? (Ambulance must be arranged by the passenger)

NoYes▸Departure point

Company nameContact Info▸Arrival point

Company nameContact Info

Destination (Hospital Name)
7

Special instructions / Precautions

ADD02-001-240401

MEDICAL INFORMATION FORM

To be completed by ATTENDING PHYSICIAN

Please fill out all of the 1–9 checkboxes/fields below. Please provide full details of any
symptoms, etc., prior to boarding the aircraft. ANA may contact the customer forclarification if necessary.

Please inform us via email or FAX(Japan). If sent by FAX, we willphone you to confirm.
FAX No.
0120-029-366 (toll-free)
03-6741-8710 (Tokyo)

PATIENTS
AGE

NAME,INITIAL(S)MEDICAL DATADIAGNOSIS in details

Please write so that non medical personnel are able understand.

(including vital signs)

Date of first symptoms/
Diagnosis(Date of Operation)

Date:

Diagnostic content
1 PROGNOSIS for the flight(s)* Please consider the itinerary and its potential
effect on the patient's state of health/

For expecting mother(Estimated delivery date)//Date:/Fit to Travel

Start of itinerary://

NOT Fit to Travel

End of itinerary://*For round-trip itineraries, please also enter the departure date of the last flight in your itinerary.

23

4Contagious AND communicable
Disease ?

Yes

Can sit upright with seat belt
fastened ?
(during take-off and landing)Yes

Is the patient fit to travel
unaccompanied?

Yes→If Yes, may the disease be infectious to other persons?

YesNo→If not, is Stretcher needed on board?
* An extra stretcher fee is requested besides the applicable fare forboth the passenger and escort.
Necessary arrangement must be made with the airline.

YesNoNoNo, Must be accompanied by Physician or Nurse
No, Must be accompanied by a person whois approved by Physician

5

Oxygen needed in flight?

6

Do you need oxygen continuously?

7

Does patient need any medical
equipment in flight?
(e.g., ventilator, oxygenconcentrator, etc.)

No

Escort name(Chaperons must sit in the adjacent seat)[Yes

If yes, please enter the amount of oxygen.

No

Liters per minute]ℓ/minute

Yes
NoYes

→If yes, specifyNo❚The Name of Medical Equipment❚Manufacturer or Distributor /* If you bring oversized medical equipment

Product name / type or model numberthat cannot be stored under the seat in front, you
may need to purchase another seat.

89Does patient need any MEDICATION inflight?

❚Size / Type of Battery

Yes→If yes, specify

NoIf there is anything you need to make us aware of prior toboarding, please provide specific details.
*Pregnancies are exempt from the filling out of a period of validity(Passenger (patient) requests that are deemed to be reasonable may also be included.)
As the patient's symptoms and condition are stable, I have determined that this MEDIF is valid until//.

Prognosis as above. I will provide necessary information required by the airline's medical department for the purposeof determining his/her fitness to travel by air with consent of the patient.
PHYSICIAN
Print Name

Date

Signature
Hospital Name
Phone No.

Address* Our cabin crew members are trained only in FIRST AID and are NOT PERMITTED to administer any injection, or to give medication, or to operate
Medical Oxygen cylinders. Additionally, they are not authorized to provide personal care services to particular passengers, to the detriment of theirservice to other passengers and cabin safety.
ADD02-001-240401