Information sheet for passengers requiring
Medical Clearance – MEDIF, part two
In accordance with IATA Resolution 700, attachment A, 29
edition, December 2010
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?
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? pCO
% Saturation Date of exam:
Does the patient retain CO
? ~ 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?
Psychiatric conditions: ~ Yes ~ No
Is there a possibility that the patient will become agitated during ﬂ ight? ~ Yes
Has he/she taken a commercial aircraft before? ~ Yes ~ No
– If yes, date of travel? Did the patient travel: ~ alone ~ escorted?
Seizure: ~ Yes ~ No
What type of seizures?
Frequency of the seizures:
When was the last seizure?
Are the seizures controlled by medication? ~ Yes ~ No
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 ﬁ rst 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