1、私人定制旅行 | 主题特色旅行 | 极地探索旅行 北京 Beijing | 广州 Guangzhou | 上海 Shanghai Web: Hotline: 400 609 0109 南极探索之旅健康报告表 General Medical Information for Antarctic Expedition Cruising 所有旅客必须完整填写表格的每一部分 All travelers must complete every section of this form No sophisticated medical facilities are available in the Ant
2、arctic. Although each vessel carries a qualified physician and a limited infirmary with basic medications and equipment, we ask that you complete this confidential medical report so that our shipboard physician is fully aware of your medical condition and needs - and can better care for you aboard.
3、在南极地区，医疗设备并不那么完善。虽然 邮轮配有一名专业医生和医务室，但我们提供的药物和医疗设备十分有限。因此，我们要求您完成这份健康报告表，对表格内容我们会予以保密。这样，我们的医生就能更好的了解您的身体状况和需求，为您的旅行提供更好的关怀 。 This expedition is intended for persons in reasonably good health. Passengers who are not fit for long trips for any reason, including disability, heart or other health conditi
4、on, are advised not to join the tour, which would entail an unreasonable risk to your health and to the enjoyment of all passengers aboard. Should any such condition become apparent, we reserve the right to decline to accept or retain you or any other passenger at any time during the trip. 南极环保行要求旅客
5、有相对健康的身体条件。不建议以下人员参与长途旅行：身有残疾，患有心脏病，以及其它的身体疾病。因为这样可能会影响患者的健康以及整个团队的旅行质量。如有检测出此类疾病，我们保留是否接受您参与此次航行的权力。 Please return this completed form with registration, including Part III, Medical Advisors Opinion. It must be received by time of final payment. This is part of our obligation for self-sufficiency u
6、nder the terms of the Antarctic Treaty System. In addition, you are advised to carry your own regular medications, which may not be available aboard. Passengers are further advised that medical evacuation, if available, is expensive, and that we strongly recommend that you have medical insurance tha
7、t will reimburse you for this cost. 请在最后付 款前把完成好的表格交给我们。包括医生建议这部分。此报告表是 邮轮在南极公约的条款下履行自我保护的责任。除此以外，我们建议您带上平时旅行用开的药物，以防船上无法提供。同时，我们提醒您，如果发生医疗事故，医疗费用是十分昂贵的，我们强烈建议您购买医疗保险以偿还医疗费用。 私人定制旅行 | 主题特色旅行 | 极地探索旅行 北京 Beijing | 广州 Guangzhou | 上海 Shanghai Web: Hotline: 400 609 0109 I attest that I am in good gener
8、al health, and capable of performing normal activities on this expedition. I further attest that I am capable of caring for myself during the expedition, and that I will not impede the progress of the expedition or the enjoyment of others aboard. I understand that this expedition will take me far fr
9、om the nearest medical facility and that all expedition members must be self-sufficient. With that understanding, I certify that I have not been recently treated for, nor am I aware of, any physical or other condition or disability that would create a hazard to myself or other members of the expedit
10、ion. 我声明我健康状况良好，可以参加此次航行的所有日常活动。同时在航行时我有能力照顾好自己，不会影响行程的正常进行和其它旅客的旅行。我明白此次旅行会远离最近的医院，所有旅客都必须独立照顾好自己。因此我在此声明，我近期没有 接受治疗，也没有任何可能会对自己或其它同行旅客造成危险的疾病。 个人基本资料 Name 名字 Date of Birth 出生日期 Date 填写日期 Height 身高 Weight 体重 Blood type 血型 Emergency contact 紧急联系人 Relationship 关系 Phone No. 联系方式 Evaluate your general
11、health: Fair/ Good/ Excellent 您的健康状况： 一般 好 极好 Evaluate your physical condition/stamina: Fair/ Good/ Excellent 您的身体状况： 一般 好 极好 Have you taken out medical insurance: Yes/ No 您是 否有购买医疗保险： 是 否 Insurances company name 保险公司名称：_ Phone number 保险公司电话 : _Contract number 合 同 号 码 ：_ 1. Do you have any medical i
12、llnesses, disabilities or infirmities that have required the regular care of a doctor? 您是否患有疾病，残疾或体弱需要医生定期检查？ Yes 是 No 否 Part 1 Health Statement / 健康声明 Part 2 Medical Information / 健康 状况 私人定制旅行 | 主题特色旅行 | 极地探索旅行 北京 Beijing | 广州 Guangzhou | 上海 Shanghai Web: Hotline: 400 609 0109 _ _ 2. List all medi
13、cations that you are taking at this time and the dosages. 请列出您正在服用的药物以及剂量。 _ _ 3. Have you been hospitalized or had surgery in the last five years? If so, when and for what? 最近 5 年您有住院或进行过手术吗？如有，请详细说明。 _ _ 4. Do you have any heart or respiratory problems? Are you a diabetic? Please elaborate. 您有心脏问题
14、或呼吸疾病吗？有患 糖尿病吗？如有，请详细列出。 _ _ 5. Do you have any dietary restrictions, food or drug allergies? If so, what are they? 您有任何的饮食禁忌吗？是否对某些食物或药物过敏？如有，请列出。 _ _ 6. Do you have any physical or mental limitations, handicaps or a prosthesis? Are you pregnant? Do you have difficulty in walking or use crutches, a
15、 cane or a wheelchair? 您是否有任何的身体或精神疾病或其它缺陷？您是否怀孕？您是否行走困难或需用到拐杖、手杖或轮椅？ 私人定制旅行 | 主题特色旅行 | 极地探索旅行 北京 Beijing | 广州 Guangzhou | 上海 Shanghai Web: Hotline: 400 609 0109 _ _ Please give this form along with your itinerary to your personal physician. 请把此表格和行程同时交给医生。 Dear Doctor,Our traveler is planning an e
16、xpedition cruise to the Antarctic, where sophisticated medical facilities are unavailable. Each vessel carries a physician and a small infirmary. While not strenuous, travelers who participate on excursions must negotiate a steep gangway, get in and out of landing boats with assistance and be capabl
17、e of walking a short distance over uneven and slippery terrain ashore. Please feel free to call us if you have any questions. 尊 敬的医生，我们的客人将会搭乘一艘 探险邮轮前往南极，然而此地的医疗设备并不够完善。虽然每艘邮轮上都配有一名专业医生和小型医务室，但是帮助甚微。所有参加长途旅行的游客都得经历陡峭的船道，出入登陆船，在凹凸光滑的南极大陆上进行短途旅行。如有任何问题，请随时联系我们。 We would like to be sure that each of ou
18、r passengers is in adequate medical condition for the voyage and that our shipboard physician is fully alerted to any potential health problems. We would appreciate your evaluation of: 我们得确保每一位旅客的身体素质都符合此次旅行对身体的要求。船上的医生会密切留意客人潜在的健康问题。鉴于您对以下项目的评估，我们表示由衷的感谢。 1. His/Her overall physical condition. 他 /她
19、整体的身体状况。 _ _ 2. His/Her ability to participate in this expedition and excursions. 他 /她参与此次探险 航行及南极大陆远足的身体评估。 _ Part 3 Medical Advisors Opinion / 医生建议 私人定制旅行 | 主题特色旅行 | 极地探索旅行 北京 Beijing | 广州 Guangzhou | 上海 Shanghai Web: Hotline: 400 609 0109 _ 3. Please elaborate on any medical conditions that you feel our shipboard physician should be aware of. 请罗列出您觉得我们的邮轮医生应该留意此客人的哪些健康问题。 _ _ Thank you for your help. 谢谢您的帮助。 Doctors name 医生姓名 _ Telephone 联系电话 _ City/State/Country 城市 / 省份 / 国家 _ Fax 传真 _ Doctors Signature 医生签名 _ Date 日期 _
