Information concerning the effect of air travel

Transport of medical patient by aircraft is, in most cases, the quickest and convenient way. Transport by aircraft has an comparative

advantages in smoothness, with less vibration and motion. However, passenger's (patient's) state of health may deteriorate consequently

from long flight time and high altitude. For these reasons, not all passengers (patients) are suitable for air travel.

Aircraft fly at an altitude of 9,000-12,000 meters (30,0000-40,000 feet) through the stratosphere at almost the speed of sound,

900km per hour (560 miles per hour). At high altitude and where barometric pressure is much lower than on ground, aircraft cabin

is mechanically pressurized during the flight. The cabin air pressure during the cruise is maintained at equivalent to that of

1,500-2,100 meters (5,000-7,000 feet) . However, cabin air pressure changes greatly during 15-30 minutes after takeoff and landings.

Air pressure:

As air pressure becomes lower, the gas trapped in the body, which dose not get discharged, expands during flight.

This may put pressure on affected parts or internal organs, and may cause pain and/or difficulty in breathing.

Oxygen density:

Person having problems with respiratory organs, heart, cerebral blood vessel and serious anemia will be affected by

decreasing oxygen density at high altitudes. Also expected mother in the final stage of pregnancy and newborn babies

may also be effected.

From above reasons, in order to assess the fitness of the passenger (patient) for air travel, person travelling with

any of the following conditions will be requested to prepare a medical certificate and submit when making a reservation.

① Person whose medical condition requires Oxygen supply (inhalation), carriage and/or use of medical equipment and/or

instruments, and any treatment onboard the flight.

② Person who needs Stretcher onboard the aircraft.

③ Person with serious sickness or injuries.

④ Person who comes under any one of the categories listed on the following page.

⑤ Other than above, person whose fitness for air travel is in doubt, as evidence by recent instability, treatment or surgery.

A credible medical certificate for an air travel must be issued within 14 days, including the day of departure, but excluding the cases below.

* For use of stretchers Must be issued within 10 days, including the day of departure
Pregnant woman whose confinement may be expected
* Must be issued within 7 days, including the day of departure
in less than 28 days
1) EDD(estimated delivery date) is within 28days from departure date
2) EDD unknown
3) Expecting multiple birth
4) Experienced premature delivery and miscarriage in the past
* For newborn baby Must be issued within 2 days, including the day of departure

(Advance reservation is possible even before the above period)

If the company determines that adverse change of the passenger's (patient's) medical condition is observed, we shall ask the

passenger (patient) to submit a new medical certificate to reconfirm the fitness for air travel.

For passengers:

Please complete "Necessary Arrangement Request", the third page of this form, including your signature

on the "Agreement" box.

You are not required to present the medical information form upon check-in,

Please be sure to send the medical information form the Priority Guest Center 48 hours prior to departure.

For attending physician:

Please complete "MEDIF", the fourth page of this form.

Please determine the fitness of the passenger (patient) for the purpose of air travel by taking the whole itinerary into

consideration. We would also appreciate any comments about the current condition and suggestion for the proposed

travel in the lower remarks space.

(Ver. SEP16)
 Guidance for the attending physician
Person who are suffering and/or suspected of having any infections or/and contagious disease shall not be accepts for air travel

Persons under the following conditions are generally considered unfit for air travel.

However, if the medical conditions or the state of health of the person is considered stable and the physician certifies the person as "Fit to Travel"

with the prognosis, passenger may be accepted for air travel after airline assessment, thus please consult with our reservation representative.

1, Critical cardiac diseases: severe cardiac failure, unstable angina pectoris, within 6 weeks after acute myocardial

infarction, uncontrolled severe arrhythmia; unstable condition after cardiac surgery including catheterization (within 21 days),

within 72 hours after angiography, within 4 days after angioplasty, pulmonary edema,

2, Thrombophlebitis of legs, deep vein thrombosis which has not been treated, pulmonary embolism.

3, Severe respiratory failure, severe COPD, severe bronchial asthma, pneumothorax that lungs are not fully inflated, haemopneumothorax,

pneumonia, emphysema, pulmonary fibrosis, within 14 days afterchest surgery,.

4, Acute phase of stroke (cerebral infarction, subarachnoid hemorrhage, intracerebral bleeding, TIA) within 4 weeks, increased intracranial

pressure, uncontrolled cramped seizure (epileptic), within 14days after cranial surgery and air remains in cranium,

5, Severe anemia, sickle cell anemia, haemoglobinopathies.

6, GIT bleed, gastro-intestinal disease with possible risk of bleeding and melena (acute phase of gastric or duodenal ulcer), ileus, within

1 week after colon polypectomy, colon tested on the day, within 14 days after major abdominal surgery including appendectomy and

laparoscopic surgery (keyhole), within 14days after investigative laparoscopy.

7, Acute phase of ENT disease (otitis media, sinusitis), within 14 days after middle ear surgery and tonsillectomy, wired jaw, difficulty

opening mouth,

8, Within 14 days after surgery and injury that any gas remains in globe (intra-ocular surgery, penetrating eye injury), cataract surgery,

corneal laser surgery,

9, Postoperative wound does not recover completely, any gas remains in the inside of the body after surgery.

10, Acute phase of decompression sickness (dysbarism).

11, Within 48hours after severe fracture with full plaster cast, burns.

12, Communicable illness which has a risk of transmission during flight (influenza, whooping cough, measles, mumps, rubella, chickenpox,

pharyngoconjunctival fever, tuberculosis, epidemic keratoconjunctivitis, acute hemorrhagic conjunctivitis, meningococcal meningitis).

As a rule of prohibition from attending school in Japan, same rule is applied for air travel. The medical certificate is not required for rubella,

chickenpox, meningococcal meningitis, tuberculosis, epidemic keratoconjunctivitis, or acute hemorrhagic conjunctivitis cases after

11 daysfrom onsets.

Disease Period when Medical Certificate is necessary

Within 5days of onset, and 2 days after temperature has
1 Influenza
dropped (3days in case of child)
Until the characteristic cough is suppressed, or until
2 Whooping cough
5days treatment with antibiotics is ended.
3 Measles 3 days after his/her temperature has dropped
Within 5days of onset of the swelling on submandibular,
4 Mumps sublingual and parotid gland, and major symptoms
general condition recovered
5 Rubella Until the eruption disappears

6 Chickenpox Until all eruption become scabs

7 Pharyngoconjunctival 2 days after the main symptom disappears

Until a physician or a pediatrician evaluates that the

8 Epidemic keratoconjunctivitis
disease becomes non-contageous.

9 Acute hemorrhagic conjunctivitis

10 Tuberculosis

11 Meningococcal meningitis

13, Pregnant woman whose EDD (estimated delivery date) is within 28 days from departing date. Escort byan obstetrician is required if EDD is

within 14 days for international flight and 7 days for domestic flight. Escort is not required if EDD is out of the above periods and obstetrician

certifies the fitness for travel.

14, Newborn baby within the first 7 days after birth. End

(Ver. SEP16)
MEDICAL INFORMATION FORM (MEDIF) To be completed by the attending physician
The attending physician is requested to answer all questions.
Enter a cross "X" in the appropriate "Yes" or "No" boxes, and/or give precise and concise answers.
Completion of this MEDIF form in BLOCK LETTERS or by TYPEWRITER will be appreciated.
<Note1> As for MEDA3, please write so that non medical personnel are able understand. As for MEDA4, please consider the effect of flight.
Cabin Attendants are not authorized to provide personal care services, such as assistance in using lavatory facilities, with eating and drinking etc.
<Note2>
Additionally they are trained only in FIRST AID and are not authorized to administer medical care service

<Note3> Additional charges will be applied for carrier provided equipments and arrangements. (To be paid by the patient)

Patient's Name,
MEDA1 Initial(s), age, gender:
Age: Gender:

p Name of the attending physician:

h
y Name of Hospital or Clinic & Address:
s profession:
MEDA2 i
c
i Telephone contact
a Business: Home:
n

Diagnosis in details (including vital signs):

MEDA3
<Note1> When did the First symptoms appear (Day/Month/Year):
（Date of Operations, if any）

Prognosis for the flight(s) Prognosis for the

MEDA4 Please consider the itinerary and its potential Fit Not Fit Return Flight Fit Not Fit
<Note1> effect on the patient's state of health (if any)
If"Yes", Specify: (e.g. The possibility of infection to others, preventive measures against
MEDA5 Contagious and/or communicable disease? Yes No → the infection etc.)

Would the physical and/or mental

condition
MEDA6 of the patient be likely to cause distress
Yes No → If"Yes", Specify:
or discomfort to other passengers?
Can the patient use normal aircraft seat
If not, is Stretcher needed on
MEDA7 with the seatback placed in the Upright Yes No →
board?
Yes No
Position when so required?
※An extra charge and adjustment of a flight are required.
Preliminary arrangements are needed with an airline.
Can the patient take care of his personal
MEDA8 needs unassisted. (use of lavatory Yes No
facilities, eating and drinking etc.) <Note 2>

If ESCORTED, is the arrangement If not, type of escort proposed

MEDA9 satisfactory to you? Yes 　 No → by you:

Can the patient travel alone? Yes No

Does passenger need Oxygen equipment If "Yes"

MEDA10 in flight? Yes 　 No → Liters per minute

Continuous use? Yes 　 No

Can the patient or escort operate

the Medical Oxygen Bottle? Yes No

(a) on the GROUND while at Airport(s):

If"Yes", Specify:
MEDA11 Does the patient need Medication other
Yes No
than self-administered, and/or the use of
specious apparatus such as respirator, ■Manufacturer：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
etc. <Note 2/Note 3> (b) on board of the AIRCRAFT:

Yes No → ■Product name：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿__

MEDA12
※All electronic equipment must be verified it's safety by the airline for onboard use.
※All electronic equipment should operate on batteries.
(a) during long layover or overnight stop at CONNECTING POINTS en rout

MEDA13 Yes No → If "Yes",Action:

Does the patient need hospitalization?
(If yes, indicate arrangements made
or, if none were made, indicate (b) upon arrival DESTINATION
"NO ACTION TAKEN".
MEDA14 Yes No → If "Yes",Action:

Other remarks or information in the

Specify if any:
MEDA15 interest of your patient's smooth and Yes No → <Note 3>
comfortable transportation.

MEDA16 Other arrangements made by the attending physician:

We would appreciate any general comment about the patient's condition and suggestion for the proposed air travel.

Prognosis as above.
Date: 　 　　　　　　　　　　　 Attending Physician:　 　　　　　　　　　　　　　　Signature (Attending Physician): 　　　　　　　　
(Ver. MAR17)
Necessary Arrangement Request <To be completed by the passenger>

Flight No. Date Month Reservation No. Portion: from to

F
L Flight No. Date Month Reservation No. Portion: from to
I
G Flight No. Date Month Reservation No. Portion: from to
H
T Flight No. Date Month Reservation No. Portion: from to

1. Do you need a wheelchair service at the airport?

No □
Yes □ Categories:
□ Requires assistance to/from the cabin seat. (WCHC)
□ Can not ascend/descend steps, but able to walk in the cabin. (WCHS)
□ Can ascend/descend steps, but requires wheelchair for walking long distance. (WCHR)

２．Are you travelling with your own wheelchair?

No □
Yes □ Please answer the questions from ① to ④
① Wheelchair size ② Wheelchair type ③ Power Source
（Weight： 　　　　　 　 kg） □ Collapsible □ Manual Wheelchair
（Width（W）：　 　　　　　　ｃｍ） □ Non-Collapsible □ Power Driven Wheelchair Is the battery removable?　□Yes □No
（Depth（D）： 　　　　　　ｃｍ） □ Seat height and angle adjustable type □ Nickel hydrogen Battery
（Height（H）：　　　　　　　ｃｍ） □ Wheelchairs using gas spring □ Nickel cadmium Battery
You are required to obtain the certificate □ Lithium-ion Battery
※ If you have a collapsible from the manufacturer stating that There are restrictions on the handling
wheelchair please input the size "IATA Dangetous Goods Regulations of Lithium Battery　*1
when it is collapsed. Special Provision A114" is met. □ Lead Battery
□ Gel Battery □ Non-Spillable Battery
□ Sillicon Battery □ Spillable Battery
④ When to check-in　*3
□ At Check-in Counter
□ At Boarding Gate
　Supplement）*1： the number of spar Lithium-ion batteries which can be carried onboard is restricted to one spare battery no greater than 300Watt hour(Wh),
or amaximum of 2spare batteries no greater　than 160Watt hour(Wh) each.
*2： Restrictions to check power driven wheelchair at boarding gate may apply due to facility and condition on the date of departure

3. Do you need a wheelchair service in the cabin? No □ Yes □

4. Do you need to use Medical Oxygen in the cabin?
No □
Yes □ □ Will you bring your personal Medical Oxygen Bottle?
□ Do you wish to use a carrier owned Medical Oxygen Bottle?
(You will need to operate the Medical Oxygen Bottles by yourself)
5. Do you need to use Stretcher in the cabin? No □ Yes □ (Personal Escort and Medical Certificate is required)

6. Ambulance use
Company Name
(Departure) No □ and Contact Details
Yes □ From:
Company Name
(Arrival) No □ and Contact Details
Yes □ Destination

7. Personal Escort 1. Name: Age: Gender: □ Physician □ Nurse □ Others (　　　　　　　)

No □ 2. Name: Age: Gender: □ Physician □ Nurse □ Others (　　　　　　　)

Yes □ 3. Name: Age: Gender: □ Physician □ Nurse □ Others (　　　　　　　)

Agreement
I here by authorize (Name of nominated attending physician)

to provide the airlines with the information, required by those airline's medical department for the purpose of determining my fitness for carriage by air and inconsideration there of,

I hereby relieve that physician of his/her professional duty of confidentiality in respect of such information and agree to meet such physician's fees in connection therewith.

Date: Passengers signature:　　　　　　　　　　　　　　　　　　　　 　

(or a Representative)

(for Airline use) Original copy of the "MEDIF" and "Necessary Arrangement Request" shall be returned to the passenger.
Departure airport shall create a copy, deliver one set to the Cabin Crew and retain another set at the departing station. (Retain for one year)
Cabin Crew shall deliver the copy to the arrival station.
(Ver. SEP16)