Medical Fitness for Air Travel Assessment
Please complete this form to assess your medical fitness for air travel. Your responses will help ensure your safety and comfort during your journey.
Traveler's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please describe your current medical condition(s) relevant to air travel.
*
Are you currently taking any medications?
*
Yes
No
If yes, please list all current medications (name and dosage). If no, write N/A.
*
Do you require any special assistance or medical equipment during the flight?
Wheelchair assistance
Oxygen supply
Stretcher
Assistance with boarding/disembarking
Other (please specify)
Treating Physician's Full Name
*
First Name
Last Name
Physician's Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician's Email Address
*
example@example.com
Date of Medical Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician's Assessment: Is the traveler medically fit for air travel?
*
Yes, medically fit for air travel
No, not medically fit for air travel
Fit with special conditions (please specify below)
If special conditions or precautions are required, please specify.
Submit Assessment
Should be Empty: