Ethiopian Airlines Medical Information Form
All patients travelling in Ethiopian Airlines with Medical conditions should provide following details.
MEDICAL INFORMATION FORM (MEDIF)
(to be completed or obtained from attending physician) (PART ONE)
(See reverse side for guiding principles)
1.Patient’s name ………………………………………………………………………………………………………………………
Date of Birth …………………………… Sex ………………… Height ……………… Weight …………………………
2.Attending physical
E-mail …………………………………………………………………………………………………………………………………………
Telephone (mobile preferred), Indicate country and area Code ………………………… Fax ……………………
3.Diagnosis (including date of 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 …………………………………………………………………………………………
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 2400 meters (8000
feet) above sea level) __Yes ___No ___Not sure
6.Additional clinical information
a. Anemia ___ Yes ___ No If yes, give recent result in grams of
hemoglobin …………
b. Psychiatric and seizure disorder ___ Yes ___ No If yes, see Part 2
c. Cardiac condition ___ Yes ___ No If yes, see Part 2
d. Normal bladder control ___ Yes ___ No If no, give mode of control …………
e. Normal bowel control ___ Yes ___ No
f. Respiratory condition ___ Yes ___ No If yes, see Part 2
g. Does the patient use oxygen at home? ___Yes ___ No If yes, specify how much ……………
h. Oxygen needed in the flight? ___ Yes ___ No If yes, specify ___ 2LPM ___4LPM
___Others
7.Escort
a. Is the patient fit to travel unaccompanied? ___ Yes ___ No
b. If no, would a meet-and- assist (provided by the airline to embark and
disembark) be sufficient?
___ Yes ___ No
c. If, no will the patient have a private escort to take care of his/her needs
on board?
___ Yes ___ No
d. If yes, who should escort the passenger? ____ Doctor ____ Nurse ____ Other
e. If other, is the escort fully capable to attend to all the above needs? ___ Yes ___ No
8. Mobility
a. Able to walk without assistance ___Yes ___No
b. Wheelchair required for boarding ___to aircraft ___to seat
9. Medication list …………………………………………………………………………………………………………………………
10. Other medical information …………………………………………………………………………………………………
MEDICAL INFORMATION FORM (MEDIF)
(to be completed or obtained from attending physician) (PART TWO)
1.Cardiac Condition
a. Angina __ Yes __ No When was last episode? …………
Is the condition stable? __ Yes __ No
Functional class of the patient?
__No symptoms __Angina with important efforts __ Angina with light efforts __ Angina at rest
Can the patient walk 100 meters at the normal pace or climb 10-12 stairs without symptoms?
___Yes ___No
b. Myocardial infraction __ Yes __ No Date ………………………………………
Complication? __ Yes __ No If, yes give details ………………………
Stress EKG done? __ Yes __ No If yes, what was the result …… Metz
If angioplasty or coronary bypass,
can the patient walk 100 meters at the normal pace or climb 10-12 stairs without symptoms?
___Yes ___No
c. 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 with important efforts
___Shortness of breath with light efforts ___ shortness of breath at rest
d. Syncope __ Yes __ No Last episode? ………………………………
Investigation? __ Yes __ No If yes, state results……………………
2. Chronic pulmonary condition __ Yes __ No
a. Has the patient had recent arterial gasses? __ Yes __ No
b. Blood gases were taken on: ____Room air _____Oxygen ____LPM
If yes, what were the results _____pCO2 ____ pO2
Saturation ……………………………………………………… Date of exam …………………………………………………
c. Does the patient retain CO2? __ Yes __ No
d. Has his/her condition deteriorated recently? __ Yes __ No
e. Can the patient walk 100 meters at a normal pace or climb 10-12 stairs
without symptoms?
__ Yes __ No
f. Has the patient ever taken a commercial aircraft in these conditions? __ Yes __ No
If yes when? …………………………………………………………………………………………………………………………
Did the patient have any problems? ………………………………………………………………………………
3. Psychiatric Conditions __ Yes __ No
a. Is there a possibility that the patient will become agitated during flight? __ Yes __ No
b. 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
a. What type of seizures? ………………………………………………………………………………………………………………
b. Frequency of seizures …………………………………………………………………………………………………………………
c. When was the last seizure? …………………………………………………………………………………………………………
d. Are the seizures controlled by medication? __ Yes __ No
5. Prognosis for the trip ___ Good ____ Poor
Physician Signature _________________ Date ________________
Note: Cabin attendants are not authorized to give special assistance (e.g. lifting) 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
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