P0995559A

MEDICAL INFORMATION FORM

(MEDIF)
PART I: To be accomplished by Sales Office/Agent PLEASE COMPLETE THE FORM IN BLOCK LETTERS
Airlines’ Name of Passenger: Sex: Age: Weight: Height:
Ref. code
MEDA 1 Bruno Benedicta Female 65 43kg 155cm
Address: 87-C Ermin Garcia St., Brgy. Pinagkaisahan, Cubao, Quezon City, Zipcode 1109.. Contact No(s): 00639193130489
MEDA 2
Her son named Benedicta Bruno
ROUTING CARRIER FLT. NO. CLASS DATE BOOKING REF.
TIP-TUN-MNL Charter flight by
the embassy of Philipine in
PROPOSED
Libya
ITINERARY

MEDA 3 NATURE OF PHYSICAL CONDITION: DEAF/MUTE OTHERS: Medical

PART II: MEDICAL INFORMATION (To be completed by ATTENDING PHYSICIAN prior to submission to PAL Medical for clearance)
(Where needed, to be read by/to passenger, dated and signed by him/her, or on his/her behalf).

“I HEREBY AUTHORIZE ___________________________________________________to provide the airlines with the information required by the
Huda Mohamed Enwegy
(Name of Nominated Physician)
airlines’ medical department for the purpose of determining my fitness for carriage by air and in consideration thereof I hereby relieve that physician of his/her professional
duty of confidentiality in respect of such information, and agree to meet such physician’s fee in connection therewith.
I take note that, if accepted for carriage, my journey will be subject to the general conditions for carriage/tariffs of the carrier concerned and the carrier does not assume
any special liability exceeding those conditions/tariffs.
I agree to reimburse the carrier upon demand for any special expenditures or costs in connection with my carriage.”

Passenger’s Signature: Place: Date:

Tajoura Heart Center, Tripoli, Libya /2020

Information written in this form shall be CONFIDENTIAL .

FOR PAL PHYSICIAN’S USE ONLY
The PHYSICIAN ATTENDING to the incapacitated passenger is requested to ANSWER
ALL QUESTIONS (Enter a cross “X” in the appropriate “yes” or “no” box and/or DATE:____________________
give precise answers).
IMPORTANT: Clearance for air travel DENIED
(**)Fees, if any, relevant to the provision of the information below, including but not limited
to OXYGEN BOTTLES, STRETCHER and/or AMBULANCE are to be paid by the Okay for BOOKING; To report to PAL Medical Clinic
passenger concerned. 4 hours before check-in time.
NOTE:
(*)Cabin Attendants are NOT authorized to give special assistance to a particular CLEARED for air travel until_______________
passenger to the detriment of their services to other passengers. Additionally, they are
trained only to render FIRST AID and are NOT PERMITTED to administer any injection _____________________________________________
or to give any medication. PRINTED NAME & SIGNATURE OF PAL PHYSICIAN
Name:
Huda Mohamed Enwegy
MEDA 4 ATTENDING PHYSICIAN
Contact Nos. Business: Home:
DM, HTN, IHD with treated bigeminy,hemorrhagic CVA on 8 May 2020.(3rd & 4th Intraventricular haemorrhage and cerbeller hemorrhage) which is resolving.
Date of Diagnosis:
MEDICAL DATA Bedridden, right side hemiparesis with 7th nerve palsy, her condition improving, conscious and oriented to TPP, gag reflux intact, bowel and bladder controlled.
Fascial palsy has improved. hemorrhagic CVA on 8 May 2020
Diagnosis in detail: BP=143/93, MAP=101, HR 98 O2 sat 96 with room air RR=18, WT=43kg, Ht =155cm.
Right side pain and numbness.
> ILLNESS: ___________
MEDA 5 (including vital signs) Concor 5mg , Nicardipine 30mg, metformin 500mg,Tahor 20 mg, omeprazole 40mg
> SURGERY: ___________
> INJURY : ___________

WHEELCHAIR needed? NO YES Wheelchair category : WCHR

Collapsible? NO YES
Own wheelchair? NO YES WCHC
MEDA 6 Battery type, spillable? NO YES
Power driven? NO YES WCHS

Wheelchairs with spillable batteries are “dangerous goods” and are permitted on passenger aircraft only under certain conditions,
which can be obtained from the airline(s). In addition, certain countries may impose specific restrictions
If YES, type of escort required:
MEDA 7 Is STRETCHER needed on board the aircraft? ** NO YES
Liters per Type of escort required:
MEDA 8 minute: Nurse (female) aand preferable with a physcian
Does patient need OXYGEN on board? ** NO YES
No. of OXYGEN
Continuous? YES NO tanks reqd.:
MEDA 9 PROGNOSIS for the trip: GOOD FAIR POOR/GUARDED
MEDA 10 Contagious/communicable disease? NO YES Specify:

MEDA 11 Is patient’s condition likely to be a source of discomfort Specify: she would be on diapers and it may have risk of odor.
to other passengers? (Odor, appearance, conduct) NO YES

Can patient use normal aircraft seat with seatback placed Remarks: she can sit upright for more than 45 mintuees which is
MEDA 12 NO YES sufficient time for take off and landing
in UPRIGHT position when required?
Can patient take care of his own needs on board UNASSISTED If NO, type of help needed:
MEDA 13 ( including meals, visit to the toilet, etc.)? NO YES 4. Adult diapers and adequate urine bagchange when neede&
helping in eating as well
A) on the GROUND while at the airport(s):
MEDA 14 Does patient need any MEDICATION *other than self-administered
NO YES Specify:
and/or the use of special apparatus such as respirator, incubator, etc.**?
B) aboard the AIRCRAFT:
MEDA 15 (Clearance with PAL Safety & Environment Department required) NO YES Specify:
A) during long layover or nightstop at CONNECTING POINTS en route?
MEDA 16
Does patient need HOSPITALIZATION? NO YES Action:
(If YES, indicate arrangements made or,
if NONE were made, indicate “NO ACTION TAKEN”) B) upon arrival at DESTINATION:
MEDA 17 Action:
NO YES
Special caution for COVID-19 prevention measures pre-during and upon arriv
Other remarks or information in the interest of your Avoiding spicy, oily and salty food. Good hydration and stretching during the flig
MEDA 18 NONE YES Specify:comfortable seats and preferably 3 seats. good hydration and stretching during the
patient’s smooth and comfortable transportation? travel.

Ambulance** NAME OF AMBULANCE: PLATE NO.: NAME OF DRIVER:

MEDA 19
requirement: NO YES

Name of companion/paramedic onboard ambulance:

MEDA 20
Embassy of Phillipine of Libya would be provding the names of the signed companion escorts

Attending Physician’s Signature: Place: National Heart Center, Date:

Tajoura, Libya /2020
Copy Distribution: 1 - Origin Stn. (WHITE) 2 - Boarding Stn.(BLUE) 3 - Destination Stn. (PINK)c/o Purser 4 - Attending Physician (GREEN) 5 - Passenger (WHITE)