诊断证明书

航空发表于 2010-4-21 09:13:27

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诊断证明书<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
1. 旅客姓名：            2.年龄：                  3.性别：              <o:p></o:p>
4. 地址(或工作单位)：                              5.电话：                            <o:p></o:p>
6. 航程：航班号<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chmetcnv w:st="on" TCSC="0" NumberType="1" Negative="False" HasSpace="False" SourceValue="8" UnitName="l">8L</st1:chmetcnv>                日期     月     日。自             至             <o:p></o:p>
联程：航班号                   日期     月     日。自              至             <o:p></o:p>
7. 诊断结果：                                                                                           <o:p></o:p>
8. 症状、程序、预后(如系孕妇需注明预产期)：                                                            <o:p></o:p>
                                                                                                            <o:p></o:p>
[注](1)上述第7、8 两项内容填写，需简单、明确。(2)下述表格中提供的内容，供机上服务人员在飞行途中为病残旅客提供必要的服务时作为参考。<o:p></o:p>
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<TBODY>
<TR style="HEIGHT: 21.15pt; mso-yfti-irow: 0; mso-yfti-firstrow: yes">
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程度<o:p></o:p>
症状<o:p></o:p></TD>
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无<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.2pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 21.15pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=86>
轻度<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.15pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 21.15pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=86>
中等<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.15pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 21.15pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=86>
严重<o:p></o:p></TD>
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备注<o:p></o:p></TD></TR>
<TR style="HEIGHT: 7.75pt; mso-yfti-irow: 1">
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贫血<o:p></o:p></TD>
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<o:p> </o:p></TD>
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<o:p> </o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.15pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 7.75pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=86>
<o:p> </o:p></TD>
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<o:p> </o:p></TD>
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<o:p> </o:p></TD></TR>
<TR style="HEIGHT: 3.5pt; mso-yfti-irow: 2">
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呼吸困难<o:p></o:p></TD>
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<o:p> </o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.2pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 3.5pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=86>
<o:p> </o:p></TD>
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<o:p> </o:p></TD>
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<o:p> </o:p></TD>
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<o:p> </o:p></TD></TR>
<TR style="HEIGHT: 10.4pt; mso-yfti-irow: 3">
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疼痛<o:p></o:p></TD>
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<o:p> </o:p></TD>
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<o:p> </o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.15pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 10.4pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=86>
<o:p> </o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.15pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 10.4pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=86>
<o:p> </o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 64.2pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 10.4pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=86>
<o:p> </o:p></TD></TR>
<TR style="HEIGHT: 7.5pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes">
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 64.15pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 7.5pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=86>
血压<o:p></o:p></TD>
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<o:p> </o:p></TD></TR></TBODY></TABLE>
9. 附注：(如有膀胱、直肠障碍或在飞行中需要特殊餐食及药物医疗处理情况等，请予以列明)<o:p></o:p>
                                                                                                            <o:p></o:p>
10. 需要何种坐姿(将下列适用的项目用○圈起)：<o:p></o:p>
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<TR style="mso-yfti-irow: 0; mso-yfti-firstrow: yes">
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乘坐姿态<o:p></o:p></TD>
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1. 使用机上一般座椅  2. 使用机上加架设备<o:p></o:p></TD></TR>
<TR style="mso-yfti-irow: 1">
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陪伴人员<o:p></o:p></TD>
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医生·护士·其他人员(具体列明)·不需要<o:p></o:p></TD></TR>
<TR style="mso-yfti-irow: 2">
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 82.5pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=110 rowSpan=2>
上下飞机时<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 55pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=73>
轮椅<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 247.5pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=330>
要·不要<o:p></o:p></TD></TR>
<TR style="mso-yfti-irow: 3">
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 55pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=73>
担架<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 247.5pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=330>
要·不要<o:p></o:p></TD></TR>
<TR style="mso-yfti-irow: 4; mso-yfti-lastrow: yes">
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 137.5pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=183 colSpan=2>
救护车<o:p></o:p></TD>
<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ffffff; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #ffffff; WIDTH: 247.5pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=330>
要·不要<o:p></o:p></TD></TR></TBODY></TABLE>
已参阅下面的资料，我院诊断认为：该旅客的健康条件在医学上能够适应上述航空旅行的要求，无传染疾病，也不致造成对其他旅客的不良影响。<o:p></o:p>
医师(签字)：                 电话：                   医疗单位(盖章)<o:p></o:p>
年  月  日<o:p></o:p>
参考资料(下述内容仅供医生在判断病人是否适于航空旅行时的参考)<o:p></o:p>
一、机上条件：<o:p></o:p>
1.飞机具有密封，增压客舱。舱内气压相当于2300公尺(7000英尺)高度的大气压力，因此能引起体腔内气体的膨胀，同时也造成轻度的缺氧状态。<o:p></o:p>
2. 飞机在飞行中会有轻微的颠簸及震动。<o:p></o:p>
3. 机上服务人员只受过一般的急救训练，但不允许为病人注射。同时，在飞行途中机上服务人员需担负整个飞机上的服务工作，无暇更多地特别照看病人。<o:p></o:p>
4. 机舱内的活动范围和舒适程度受到机舱技术设备的一定限制。<o:p></o:p>
二、处于下述状况的病人，一般不适于航空旅行：<o:p></o:p>
1. 处于极严重或危急状态的心脏病患者。如严重的心力衰竭，出现紫绀症状或心肌梗塞者(在旅行前六周之内增发生过梗塞者)。<o:p></o:p>
2. 出生不满14天的婴儿。<o:p></o:p>
3. 孕妇。怀孕期限超过36周者(怀孕期在36周以内超过32周的孕妇乘机，需具有医生在72小时之内签署的诊断证明书)。<o:p></o:p>
4. 血色素量在50%(Hb<st1:chmetcnv w:st="on" TCSC="0" NumberType="1" Negative="False" HasSpace="False" SourceValue="8" UnitName="g">8g</st1:chmetcnv>.dl)以下的贫血病人。<o:p></o:p>
5. 严重的中耳炎，伴随有耳咽管堵塞症的患者。<o:p></o:p>
6. 近期患自发性气胸的病人或近期做过气脑造影的神经系统病症的患者。<o:p></o:p>
7. 大纵隔瘤，特大疝肿及肠梗阴的病人；头部损伤，颅内压增高及颅骨骨折者；下颌骨骨折最近使用金属线连接者。<o:p></o:p>
8. 酒精或其他毒品中毒者；患有精神病，易于伤人或自伤行为者。<o:p></o:p>
9. 近期进行过外科手术，伤口未完全愈合者和产妇产后不满二周者。<o:p></o:p>
10. 在过去30天内患过脊髓灰质炎的病人；延髓型脊髓灰质炎患者。<o:p></o:p>
11. 下列传染病或疑难病患者：霍乱、伤寒、副伤寒、发疹性斑疹伤寒、痢疾、天花、猩红热、白喉、鼠疫、流行性脑炎、脑膜炎、开放期的肺结核及其他传染病。<o:p></o:p>
12. 带有传染性或损伤、使其他旅客感到厌恶的皮肤病患者。<o:p></o:p>
13. 带有严重咯血、吐血、呕吐、呻吟症状的患者。<o:p></o:p></TD></TR></TBODY></TABLE>
本单为一式三联：第一联为出票联，由出票单位留存；第二联为乘机联，交始发站值机部门留存；第三联为到达联，交到达站服务部门留存。<o:p></o:p>

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