LX Medif-Form en

Information sheet for passengers requiring
Medical Clearance – MEDIF, part one

In accordance with IATA Resolution 700, attachment A, 29 th edition, December 2010
Note for the attending physician:

The details requested in here will be treated confidentially; they should enable the Medical Services of the airline(s), as it is their obligation, to judge
by their specific air medical knowledge and experience if and under what conditions the patient can be permitted to travel by aircraft as requested.
These details will also help the Medical Service in issuing appropriate instructions for the patient’s care which duly consider both his/her diagnosis and
the special circumstances of the requested air journey. Kindly answer all questions by cross or in block letters, as necessary. Please fill in this form on
your PC to enhance readability and clarity. You can easily typewrite into the grey fields. Thank you for your cooperation!
1. Patient
Name, first name:
Date of birth: Sex: Height: Weight:
2. Attending physician
Name:
Address: Phone:
E-Mail: Fax:
3. Diagnosis (including short history, onset of current illness, episode or accident and treatment, specify if contagious)
Nature and date of any recent and/or relevant surgery:

4. Current symptoms and severity Date of onset:
5. Will a 25% to 30% reduction in the ambient partial pressure of oxygen (relative hypoxia) aﬀect the passenger’s medical condition? (Cabin
pressure to be the equivalent of a fast trip to a mountain elevation of 2,400 meters (8,000 feet) above sea level)
~ Yes ~ No ~ Not sure
6. Supplementary information
Anaemia: ~ Yes ~ No If yes, give date: and result of
recent haemoglobin analysis gm/dl
Psychiatric conditions: ~ Yes ~ No If yes, see Part 2
Cardiac disorder: ~ Yes ~ No If yes, see Part 2
Normal bladder control: ~ Yes ~ No If no, give mode of control:
Normal bowel control: ~ Yes ~ No
Respiratory disorder: ~ Yes ~ No If yes, see Part 2
Does the patient require oxygen at home? ~ Yes ~ No If yes, specify how much l/min (LPM):
Oxygen needed during flight? ~ Yes ~ No If yes, specify, ~ 2 l/min ~ 4 l/min
Seizure disorder: ~ Yes ~ No If yes, see Part 2
7. Escort
Is the patient fit to travel unaccompanied? ~ Yes ~ No
If no, would a meet-and-assist (provided by the airline to embark and disembark) be suﬃcient? ~ Yes ~ No
If no, will the patient have a private escort to take care of his/her needs on board? ~ Yes ~ No
If yes, who should escort the passenger? ~ Doctor ~ Nurse/Paramedic ~ Other
If other, is the escort fully capable to attend to all above mentioned needs? ~ Yes ~ No
Is the patient able to sit in a usual aircraft seat (seatback in upright position)? ~ Yes ~ No
8. Mobility
able to walk without assistance: ~ Yes ~ No Wheelchair required for boarding: ~ to aircraft ~ to seat
9. Medication list (incl. doses):
10. Other medical information:
Information sheet for passengers requiring
Medical Clearance – MEDIF, part two
In accordance with IATA Resolution 700, attachment A, 29 th edition, December 2010
1. Cardiac condition: ~ Yes ~ No
Angina: ~ Yes ~ No When was last episode?

– Is the condition stable? ~ Yes ~ No
– Functional class of the patient? (CSS) ~ Angina with strenuous activity ~ with moderate activity
~ with mild activity ~ with rest or minimal activity
– Can the patient walk 100 metres at a normal pace or climb 10–12 stairs without symptoms? ~ Yes ~ No
Myocardial infarction: ~ Yes ~ No Date:

– Complications? ~ Yes ~ No If yes, give details:
– Stress EKG done? ~ Yes ~ No If yes, what was the result? MET’s or Watt
– If angioplasty or coronary bypass, can patient walk 100 yards/metres
at a normal pace or climb 10–12 stairs without symptoms? ~ Yes ~ No
Cardiac failure: ~ Yes ~ No When was last episode?

– Is the patient controlled with medication? ~ Yes ~ No
– Functional class of the patient? ~ No symptoms ~ Shortness of breath (SOB) with moderate exertion
~ SOB with minimal exertion ~ Shortness of breath at rest
Syncope: ~ Yes ~ No When was last episode?

– Investigations: ~ Yes ~ No If yes, state results?
2. Chronic pulmonary condition: ~ Yes ~ No
Has the patient had recent arterial blood gases? ~ Yes ~ No
Blood gases were taken on ~ Room air ~ Oxygen Litres per minute (LPM)
– If yes, what were the results? pCO2 [kPa/mmHg] pO2 [kPa/mmHg]
% Saturation Date of exam:
Does the patient retain CO2? ~ Yes ~ No
Has his/her condition deteriorated recently? ~ Yes ~ No
Can patient walk 100 yards/metres at a normal pace or climb 10–12 stairs without symptoms? ~ Yes ~ No
Has the patient ever taken a commercial aircraft in his/her current medical status? ~ Yes ~ No
– If yes, when?
– Did the patient have any problems?
3. Psychiatric conditions: ~ Yes ~ No
Is there a possibility that the patient will become agitated during flight? ~ Yes ~ No
Has he/she taken a commercial aircraft before? ~ Yes ~ No
– If yes, date of travel? Did the patient travel: ~ alone ~ escorted?
4. Seizure: ~ Yes ~ No
What type of seizures?
Frequency of the seizures:
When was the last seizure?
Are the seizures controlled by medication? ~ Yes ~ No
5. Prognosis for the trip: ~ Good ~ Poor
Signature of physician (or facsimile): Date:
Note: Cabin attendants are not authorized to give special assistance (e.g. lifting, meals) to particular passengers, to the detriment of their service to other passengers. Additionally, they are trained only in first aid and
are not permitted to administer any injection, or give medication. Important: Fees, if any, relevant to the provision of the above information and for carrier-provided special equipment are to be paid by the passenger
concerned.
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Information sheet for passengers requiring

Medical Clearance – MEDIF, part one

Note for the attending physician:

Nature and date of any recent and/or relevant surgery:

1. Cardiac condition: ~ Yes ~ No

Angina: ~ Yes ~ No When was last episode?

Myocardial infarction: ~ Yes ~ No Date:

Cardiac failure: ~ Yes ~ No When was last episode?

Syncope: ~ Yes ~ No When was last episode?

Signature of physician (or facsimile): Date:

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