Medical Travel Passport

의료 여행 여권

직접 작성·다운로드·인쇄하는 개인 의료 요약: 진단과 치료 요약, 약물과 알레르기, 투석 처방 또는 이식 정보, 의료진과 비상 연락처. 인쇄본은 중국어/영어(일본어 선택) 이중 언어 항목입니다.

개인정보 설계: 입력한 모든 내용은 이 기기의 브라우저(localStorage)에만 저장되며 이 사이트나 어떤 서버에도 전송되지 않습니다.

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.