MEDICAL DECLARATION

Form Number : xxxxxxxx This form is intended to provide confidential information to enable the airline's
Ground Officer and Aircrew to asses the fitness of the passenger to travel by air
To be completed by and give the necessary directives designed to provide for
attending physician the passenger's welfare and comfort

Passenger's name : Address :

01 Sex :
Age : Phone :

Flight No. : Class : F / C / Y Date : Departure Time :

From : ………..…………..………….. To ……………...…….…………………………………………..…..…… (direct flight)
02
From : ……..…………..…………….. To ……………….………………… Via ………………………..……… (without/with connecting)
Transfer Flight at : ……………………………………………… Flight Nbr. ……………………………………..

Diagnosis : …………………………………………………………………………………………………………………………………………………
General Condition State of Consiousness : composmentis precomatose comatose

Physical Strength : normal weak paralysed

Specify : ………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
Blood Pressure : ………………...……… Heart Rate : ………………....………. Body Temperature : …………………..

Anemia : No Yes, Hemoglobin ……………………………..............................

Dyspnoe : No Yes, Degree : mild moderate severe

03
Pain : No Yes, Degree : mild moderate severe

Contagious and communicable disease ? : No Yes, Specify : ………………………………………………………

Is patient in any way offensive to other
passenger ? (smell, appearance, conduct) : No Yes, Specify : ………………………………………………………

Recent heart attack ? : No Yes, Specify : …………………… When? ………………………

Recent operation ? : No Yes, Specify : …………………… When? ………………………

Malfunction of the bladder or bowels : No Yes, Specify : ………………………………………………………

Other Symptoms : ………………………………………………………………………………………………………………………………………

Does patient need intravenous treatment/nutrition during flight ? No Yes

Does patient need oxygen during flight ? No Yes, Specify : - Rate of flow …………………………. L/minute

04 - Continuous No Yes

Does patient need special apparatus such respirator, incubator etc No Yes

Does patient need medication during flight ? No Yes, Specify :…………………………………………………….….

05 Prognosis for the trip : …………………………………………………………………………………………………………………………………...

Based on the information above and having read the guiding principles overleaf,

I herewith declare that this passenger is FIT UN FIT ; to undertake the above
journey by air, provided that the passenger is given the following arrangements or is treated as follows :
A) Degree of ambulation :

Sitting case Wheel chair case Stretcher case

B) The passenger will not be escorted / will be escorted by :

Doctor Nurse Other

( all stretcher cases must be escorted )
C) Special arrangements needed (i.e. oxygen, etc which should be provided by Sriwijaya Air)
…………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………

Note : Flight Attendants are not authorized to give special assistance to Important : Fees if any, relevant to the provision of the
particular passengers, to the detriment of their service to other above information and for Sriwijaya Air -
passengers. provided special equipment are to be paid
Additionally, they are trained only in First Aid and are not by the passenger concerned.
permitted to administer any injection or to give medication.

Attending physician's name : Approved by Supervisor On Duty : Pihak Airlines

Address : Date : Name :

Phone : Signature : Date :

Cap Rumah Sakit

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