Medical Travel Passport

Passeport médical de voyage

Un résumé médical personnel que vous remplissez, téléchargez et imprimez vous-même : diagnostic et traitement, médicaments et allergies, prescription de dialyse ou informations de greffe, équipe soignante et contacts d’urgence. L’impression utilise des libellés bilingues chinois / anglais (japonais en option).

Confidentialité par conception : tout ce que vous saisissez est stocké uniquement dans le navigateur de cet appareil (localStorage) et n’est jamais envoyé à ce site ni à aucun serveur.

Personal informationPersonal information

Full name Full name Name as in passport Name as in passport Date of birth Date of birth Sex Sex Blood type Blood type Weight (kg) Weight (kg) Languages I speak Languages I speak Travel insurance company / policy no. / phone Travel insurance company / policy no. / phone

Diagnosis and treatment summaryDiagnosis and treatment summary

Current status Current status Primary kidney disease / cause Primary kidney disease / cause Other diagnoses (hypertension, diabetes, heart disease…) Other diagnoses (hypertension, diabetes, heart disease…) Recent key labs (date, creatinine, eGFR, potassium, hemoglobin, drug level) Recent key labs (date, creatinine, eGFR, potassium, hemoglobin, drug level) Important alerts Important alerts

Current medications and allergiesCurrent medications and allergies

Immunosuppressants (generic name, dose, timing, target level) Immunosuppressants (generic name, dose, timing, target level) Other medications (generic name, dose, frequency) Other medications (generic name, dose, frequency) Drug allergies and adverse reactions Drug allergies and adverse reactions Medicines to avoid Medicines to avoid

Dialysis prescription (for dialysis patients)Dialysis prescription (for dialysis patients)

Schedule (days, hours per session) Schedule (days, hours per session) Dry weight (kg) Dry weight (kg) Vascular access (site, type) Vascular access (site, type) Needle gauge / blood flow / dialysate flow Needle gauge / blood flow / dialysate flow Dialyzer / modality (HD / HDF) Dialyzer / modality (HD / HDF) Dialysate (K, Ca, bicarbonate) Dialysate (K, Ca, bicarbonate) Anticoagulation Anticoagulation ESA / iron / other intradialytic drugs ESA / iron / other intradialytic drugs Hepatitis B / C / HIV serology (date and result) Hepatitis B / C / HIV serology (date and result) PD prescription (if applicable) PD prescription (if applicable)

Transplant information (for recipients)Transplant information (for recipients)

Transplant date Transplant date Donor type Donor type Graft location Graft location Transplant center Transplant center Rejection / infection history, CMV / EBV status, other Rejection / infection history, CMV / EBV status, other

Care team and emergency contactsCare team and emergency contacts

Primary physician (name, specialty) Primary physician (name, specialty) Hospital and country Hospital and country Hospital / dialysis unit phone (with country code) Hospital / dialysis unit phone (with country code) Hospital or coordinator email Hospital or coordinator email Emergency contact 1 (name, relationship, phone) Emergency contact 1 (name, relationship, phone) Emergency contact 2 Emergency contact 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.