MED-FLY

Medical Evaluation for FAA 8500-8 Form



Notice and Instruction Page: Click on Image.
Application For: Class of Medical Certificate Applied For:
Last Name: Suffix:
First Name: Middle Name:
Social Security Number: Date of Birth:
- - / / MM / DD / YYYY
Home Phone: Business Phone:
Home Address: Business Address:
Occupation: Employer:
E-mail: Citizenship:
Height in Inches:   Weight in Pounds:   Color of Hair:   Color of Eyes:   Sex:  
Inches Pounds


Type of Airman Certificate(s) Held:

None
Airline Transport
Commercial
ATC Specialist
Flight Engineer
Flight Navigator
Flight Instructor
Private
Student
Recreational
Other


Has Your FAA Airman Medical Certificate Ever Been
Denied, Suspended or Revoked?

YesNo
If yes, give date: - MM - YYYY


Total Pilot Time (Civilian Only).

To Date: Hrs.
Past 6 Months: Hrs.


Date of Last FAA Medical Application.

- MM - YYYY
No Prior Application.


Do You Currently Use Any Medication?
(Prescription or Non prescription)


If Yes, give:
Name
Purpose
Dosage
Frequency
Yes
1st Med.
Yes
2nd Med.
Yes
3rd Med.
Yes
4th Med.
No
If Medication is
not being taken
at this time then
Check "No"
If "Yes" is checked,
for a medication that is
being taken presently.
Please indicate with a
"Yes" or "No"
if the medication was
Previously Reported.

1st Med.

2nd Med.

3rd Med.

4th Med.

Yes No

Yes No

Yes No

Yes No


Do You Ever Use Near Vision Contact Lens(es) While Flying?

YesNo


Medical History

HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING?  Answer "yes" for every condition you have ever had in your life.  In the EXPLANATION BOX below, you may note "PREVIOUSLY REPORTED, NO CHANGE" only if the explanation of the condition was reported on a prior application for an airman medical certificate and there has been no chance in your condition.


Yes
No
Condition
a. Yes No Frequent of severe headaches
b. Yes No Dizziness or fainting spell
c. Yes No Unconsciousness for any reason
d. Yes No Eye of vision trouble except glasses
e. Yes No Hay fever of allergy
f. Yes No Asthma of lung disease
g. Yes No Heart or vascular troubles
h. Yes No High or low blood pressure
i. Yes No Stomach, liver, or intestinal trouble
j. Yes No Kidney stone or blood in urine
k. Yes No Diabetes
l. Yes No Neurological disorders; epilepsy, seizures, strokes, paralysis, etc.
m. Yes No Mental disorders of any sort; depression, anxiety, etc.
n. Yes No Substance dependence of failed a drug test ever; or substance
abuse or use of illegal substance in the last 2 years.
o. Yes No Alcohol dependence or abuse
p. Yes No Suicide attempt
q. Yes No Motion sickness requiring medication
r. Yes No Military medical discharge
s. Yes No Medical rejection by military service
t. Yes No Rejection for life or health insurance
u. Yes No Admission to hospital
x. Yes No Other illness, disability, or surgery

Conviction and/or Administrative Action History


v. Yes No History of (1) any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug: or (2) history of any conviction(s) or administrative action(s) involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving privileges or which resulted in attendance at an educational or a rehabilitation program.
w. Yes No History of nontraffic conviction(s) (misdemeanors or felonies).


Explanations Box




Visits to Health Professional Within Last 3 Years


If Yes, give: Date
MM-YYYY
Name
Type of Health Professional Consulted
Address Reason
Yes 1st
-



Yes 2nd
-



Yes 3rd
-



Yes 4th
-



No


Applicant's National Driver Register and Certifying Declarations:

PLEASE READ!


Med-Fly Appointment Date:

/ / MM / DD / YYYY


If you have any concerns about your medical history.  SUBMIT this form to our Senior FAA Aviation Medical Examiner.

               


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