Medical Travel Passport

A personal medical summary you fill in, download and print yourself: diagnosis and treatment summary, medications and allergies, dialysis prescription or transplant details, care team and emergency contacts. The printout uses bilingual Chinese / English labels (Japanese optional).

Privacy by design: everything you type is stored only in this device's browser (localStorage) and is never sent to this site or any server. Clearing browser data deletes it.

Personal information基本資料

Full name 姓名 Name as in passport 護照英文姓名 Date of birth 出生日期 Sex 性別 Blood type 血型 Weight (kg) 體重（公斤） Languages I speak 可溝通語言 Travel insurance company / policy no. / phone 旅遊保險公司／保單號／電話

Diagnosis and treatment summary疾病與治療摘要

Current status 目前狀態 Primary kidney disease / cause 原發腎病／病因 Other diagnoses (hypertension, diabetes, heart disease…) 其他診斷（高血壓、糖尿病、心臟病…） Recent key labs (date, creatinine, eGFR, potassium, hemoglobin, drug level) 最近重要檢驗值（日期、肌酸酐、eGFR、鉀、血紅素、藥物濃度） Important alerts 重要注意事項（請以粗體寫法強調）

Current medications and allergies目前用藥與過敏

Immunosuppressants (generic name, dose, timing, target level) 免疫抑制劑（學名、劑量、服用時間、目標濃度） Other medications (generic name, dose, frequency) 其他藥物（學名、劑量、頻次） Drug allergies and adverse reactions 藥物過敏與不良反應 Medicines to avoid 請避免使用的藥物

Dialysis prescription (for dialysis patients)透析處方（透析患者填）

Schedule (days, hours per session) 透析排程（週幾、時數） Dry weight (kg) 乾體重（公斤） Vascular access (site, type) 血管通路（位置、類型） Needle gauge / blood flow / dialysate flow 針號／血流速／透析液流速 Dialyzer / modality (HD / HDF) 透析器／模式（HD／HDF） Dialysate (K, Ca, bicarbonate) 透析液（鉀、鈣、碳酸氫鹽） Anticoagulation 抗凝劑 ESA / iron / other intradialytic drugs ESA／鐵劑／其他透析中用藥 Hepatitis B / C / HIV serology (date and result) B 肝／C 肝／HIV 檢驗（日期與結果） PD prescription (if applicable) 腹膜透析處方（如適用）

Transplant information (for recipients)移植資訊（移植患者填）

Transplant date 移植日期 Donor type 捐贈類型 Graft location 移植腎位置 Transplant center 移植醫院 Rejection / infection history, CMV / EBV status, other 排斥／感染病史、CMV／EBV 狀態、其他

Care team and emergency contacts醫療團隊與緊急聯絡

Primary physician (name, specialty) 主治醫師（姓名、科別） Hospital and country 醫院名稱與國家 Hospital / dialysis unit phone (with country code) 醫院／透析室電話（含國碼） Hospital or coordinator email 醫院或個管師 Email Emergency contact 1 (name, relationship, phone) 緊急聯絡人 1（姓名、關係、電話） Emergency contact 2 緊急聯絡人 2

This template was designed by a patient and is not an official medical document. Your doctor's written summary takes precedence; please have your care team review the content before travelling. Fill in fields in English or the local language so staff abroad can read them.