MEDIF Form | Medical Flight Patient Information

MEDIF – Medical Information Form

Enter the clinical information required for airline medical assessment and transfer planning in English.

This MEDIF record is collected only through the secure web form. If the airline requires its own current MEDIF document, that carrier procedure is handled separately during the operation.

Patient

Name Surname *

Gender

Date of Birth

Nationality

Admission Details

Hospital / Facility Name

Admission Date

Diagnosis / Clinical Condition *

Patient Categorization

Patient without acute threat to life but requiring hospitalizationInjury/disease that could lead to deterioration of vital signsPatient with acute life-threatening conditionPatient requiring intensive care

Infection / Contagious Risk

Pathogen

Vital Parameters

Blood Pressure

Temperature

Heart Rate

SpO₂

Respiratory Rate

Neurologic

Pupils

Abnormal Description

GCS Eye

GCS Verbal

GCS Motor

Consciousness

Mobility

Pain /10

Breathing & Circulation

Breathing Status

Oxygen L/min

Other Breathing Note

Circulation

Laboratory

HGB

HCT

WBC

PLT

Glucose

Creatinine

CRP

Lactate

ABG pH

ABG pO₂

ABG pCO₂

ABG HCO₃

ABG BE

Lines & Catheters – Day

Peripheral IV

Chest Tube

Central Venous Line

Nasogastric Tube

PICC Line

Foley Catheter

Arterial Line

Other

Ventilator Settings

Vt [mL]

Trigger [L/min]

Freq [1/min]

PEEP [mbar]

Pmax [mbar]

I:E

FiO₂ %

Tplat %

Mode

Patient Dimensions

Weight – kg

Height – cm

Shoulder Width – cm

Abdomen incl. arms – cm

Hip Width – cm

Medications & Fluids

Generic Name / Active Substance	Dose	Route

Fitness-to-Fly Comments

Comments on fitness to fly / air ambulance suitability

Extra Notes

Form Filled In By

Full Name

Position

Contact Number

Date

Medical Data Notice / Explicit Consent Notice

I have read and been informed by the Medical Data Notice. View Details
Because I choose to submit health data through this form, I have read and accept the Explicit Consent Notice for processing the data to assess the request and coordinate medical transfer. View Details

Security Code: 4 + 5 =

MEDIF – Medical Information Form

MEDIF – Medical Information Form

Plan the medical transfer from one coordination point.