指定の診断書

INFORMATION
PART
SHEET
U
o
roflici副
use
o
n
l
v
l
TM。PhAfEim町sDelfCan1rAemhLceeO恒Msespal町na1FW叫
tdrntihre ce t岡isvmt田
e。swda叩
sews egdrsnBl$setCdacoetcomfeiptmneeoeaMEs削de。e s帥
t除othrLetIhmnpef aompsrams esnaeatgln開lmegret制rots。ltwl 阿
armeMe旬d剛r出aes向aMnd向dfωcs山saumtlefa問
mOde凡lsn
PART 2
ThePHYSICtANATTEND1NGt
h
el
n
E
S
p
a
c
u
a
t
e
dp
a
s
s
e
n
H
E
F
e
e
r
s
H
I
s
E
r
e
r
q
"
u
n
e
o
s
e
t
e
b
d
o
E
x
O
e
ANEVVERALL
aUESTJONS.IEmerac
r
o
s
s.提唱 i
nt
h
ea
p
p
r
o
p
r
j
a
t
e"
y
e
s
"o
'"
n
o
"b
o
x
e
s
.and/o
rg
i
v
e
p
r
e
c
i
s
ec
o
n
c
i
s
ea
n
s
w
e
r
s
)
AYTTEeNDb・,NmG同mPHzMV・SE回IcrAN
Ai ,1刷"
COMPLETING OFTHE FOAM IN
APPAECIATEO
日 LOCK
LETTERSOAB'
r
' TYPEWRITEA WILL BE
ー The
f
o
r
mmU$tberetumed10・
,
ICa rier's D
e
s
l
g
n
a
l
e
dOffic剖
PATIEN侒 NAME.I
N
I
T
I
A
U
S
)
.S
E
X
.AGE:
Ref
.Code
MEDA01
ATTENOJNGPHYSICIAN
.Add ess
-Name&
,
MEDA0~
-T
e
l
e
p
h
o
n
eC
o
n
l
a
c
l
I Busin 出
MEDICALOATA:
ー OIAGNQSIS i
nd
e
l
a
i
l
s
lincludin由 vilal5i由,,)
時国田
ー Oay/mon1h/yea ,
MEOA04
,
-PROGNOSIS1
0
'l
h
el ip:
Cca酬抽.,出叫
ease'
州D
MEOA05
"
"
MEOA06
n
d
/
o
rm
e
n
t
a
lcond巾加白f t
h
epetl・nz,tr
s
?
• Would1
h
lphysi伺 1 .
a
s
s
e
n
g
bel
i
k
e
l
yt
oc
l
u
s
ed
i
s
t
r
e
s
s0
1d
i
s
c
o
m
l
o
r
t1
0oth由r p
MEDA07
-Canp
a
l
i
e
n
lu
s
en
o
r
m
a
la
i
r
c
r
a
l
1s
e
a
l
W
i
1
hs
e
a
l
b
a
c
kp
l
a
c
e
di
nt
h
eU?AIGHT
posit巾n w
hens
o'
e
q
u
i
'
e
d
?
MEDA0B
.Canp
a
t
i
e
n
tt
a
k
eca e 0
1h
i
sownneeds
00'ロard UNASSISTEO ・ lincluding m
e
a
l
s
.
v
i
s
i
l1
01
0
i
l
e
l
.e
1
c
.
)
?
MEDA09
MEDA10
1
h竺竺竺:
0
1l
i
'
S
Isymp10ms:'
N.[ コ
yes [コ s,回
陶口
Yω 口 SpeCil
,
Ye~ 口
N,口
y" 口
N. 口
I
fnt I
y
p
e
0
1h
e
l
pneeded
,
V騎口
晶 lf t
obeESCORTEO JEF
EI
h
Ea
r
d
rasnaBtIedmaecntロt
,.ロPOsed i
nPARTl
/
Ehereol
町
f
o
ry
o
u
?
N. 口
1
In
0
1
.t
y
p
e0
1e
s
c
O
I
Ip
r
o
p
o
s
e
dby'
r
'QU:
晶 DeEqtoaueteso
m
p
r
a
a
e
t
u
E
n
e
t
d
n
m
E
f
n
f
l
o
H
e
w
g
e
h
}
d
t
O
YG
E
N-?X
I
L
I
y
e
s
.
y" 口
N. [コ
L
1
tr
e
s
~_~~~_ c二コ
M
i
n
u
1
e
C
o
n
l
i
n
u
o
u
s
?
V防亡コ
N. Lコ
l
a
l onl
h
eGAOUNDw
h
i
l
ea
l1
h
ea
i
r
p
or
!(
s
)
:
MEOAll
D
M
o
E
e
D
s
I
C
p
A
a
t
T
s
e
l
D
n
t
Nneedanv
出口
01ehreefd+
1
h
a
nself・adm'n+1引
a
n
d
/
o
rI
h
euseS
o
u
f
c
s
h
p
a
e
s
c
i
a
la
p
p
a
r
a
l
u
s
10)
resprralo仁川 cubalor.
MEDA12
出仁コ
, [コ
SATI酬
N
,,
‘
Y回仁コ
Speclly咽
l
a
l d
u
r
i
n
gl
o
n
gl
a
y
o
v
e
ro
rn
i
g
h
1
S
1
0
pa
1CONNECTINGPQINTSenr
o
u
1
e
ー DHoOeSsPpITaAtBLeInE tneed
11y
e
s
.i
n
d
i
c
a
1
e
'
aorrra nfg
n
e
m
m
e
e
n
w
t
E
e
r
m
eade
MEDA14
S
p
e
c
i
l
y
:
0
11
h
eAIRCRAFT:
elc. ・.,
j
MEDA13
ロ, bロard
Y回口
made. i
n
d
i
c
a
t
e
NOACTIONTAKEN'"
Yes [コ
I
b
l upona
r
r
i
v
a
la
lOESTINATION:
N. 亡
[ゴ
'
r
'e
s
A
c
t
i
o
n
-D
l
h
e
rr
e
m
a
r
k
so
r
i
n
f
o
r
m
a
t
i
o
ni
nt
h
e
MEDA15
。uロ,,"
E
p
n
a
t
t
e
t
r
e
e
n
s
r
t
s
o
s
f庁v、o
N間口
S
p
e
c
i
l
yi
lany・・
andc
o
m
l
O
'
l
a
b
l
e
t
r
a
n
s
p
o
r
t
a
t
l
o
n
:
MEDA16
NOTEI・1‘
-Othera
r
v
r
a
t
n
h
g
-emenIS
m
p
h
a
F
d
S
e
I
E
1
b
a
y
n
: a
t
t
e
n
d
1
n
g
Cabm a
ttendantsare NOTauthDHzedt
og
o
N
f
e
thEepwec田
latm
a
c
s
e
s
i
s
t
a
n
c
et
o
,
ppPaaErsRtsIMceun汀lgaTerErsD
p-atsAosdeadndigtrnieolrnnslazItlevtoa
r
t
a
h
n
t
e
h
y
v
e
a
I
n
r
i
e
d
-B
t
r
i
t
n
n
t
I
O
O
t
h
e
r
t
r
a
i
n
e
d
o
n
l
yi
nFIRSTAIDand
a
r
e
N
D
T
D副自:
IMPORTANT: F
E
E
S
.I
F AN'
r
'
. RELEVANT TO THE P
ROVISION QF THE ABQVE
INFOAMAT旧N ANDFORC
ARAIEA-PAOVIDEDSPECIALEOUIPMENT
(
"
)AAETOBEPAIOBYTHEPASSENGERCONC正 ANEO
nyi
n
j
e
c
1
i
o
n
.0
'1
0g
i
v
eIT可 edicalion
'"ω
1
<7015051