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for which the applicant’s licence and ratings are valid may be
used.
MEDICAL IN CONFIDENCE
MEDICAL EXAMINATION REPORT
For use by designated medical examiners only
(4) National Identification number (if applicable)
(1) Examination
Category
Initial □
Renewal □
Special Referral □
(2) Height
cm
(3) Weight
kg
(4) Eye
Colour
(5) Hair
Colour
(6) Blood Pressure –
seated mmHg
(7) Pulse – resting
Systolic Diastolic Rate (bpm) Rhythm
Reg □
Irreg □
Clinical examination: Check each item Normal Abnormal Normal Abnormal
(8) Head, face, neck, scalp (18) Abdomen, hernia, liver, spleen
(9) Mouth, throat, teeth (19) Anus, rectum (indicate if not examined)
(10) Nose, sinuses (20) Genito-urinary system (indicate if not examined)
(11) Ears, especially eardrum appearance and
motility
(21) Endocrine system
(12) Eyes – orbit and adnexa, visual fields (22) Upper and lower limbs, joints
(13) Eyes – pupils and optic fundi (23) Spine, other musculoskeletal
(14) Eyes – ocular motility, nystagmus, eye muscle
balance
(24) Neurologic – reflexes, etc.
(15) Lungs, chest, breasts (indicate if breasts not examined) (25) Psychiatric
(16) Heart (26) Skin and lymphatics
(17) Vascular system (27) General systemic
(28) Notes: Describe every abnormal finding. Enter applicable item number before each comment.
(29) Identifying marks, tattoos, scars etc
Visual acuity
(30) Distant vision at 6 m Glasses Contact lenses
Uncorrected
Right eye Corrected to
Left eye Corrected to
Both eyes Corrected to
(31) Intermediate vision Uncorrected Corrected
N14 at 100 cm Yes No Yes No
Right eye
Left eye
Both eyes
(32) Near vision Uncorrected Corrected
N5 at 30–50 cm Yes No Yes No
Right eye
Left eye
Both eyes
(33) Spectacles (234) Contact lenses
Yes □ No □
Type:
Yes □ No □
Type:
(35) Colour perception Normal □ Abnormal □
Pseudo-isochromatic plates Type:
No of plates: No of errors
(40) Hearing
(when 241 not performed)
Right ear Left ear
Conversational voice test at 2 m
back turned to examiner
Yes □
No □
Yes □
No □
(41) Audiometric screening
Hz 500 1000 2000 3000
Right
Left
(50) Urinalysis Normal □ Abnormal □
Glucose Protein Blood Other
(60) Mental health aspects of fitness discussed
Yes □ No □
(61) Behavioural aspects of fitness discussed
Yes □ No □
(62) Physical aspects of fitness discussed
Yes □ No □
(63) Preventive health advice given:
Yes □ No □
Accompanying
Reports
Normal Abnormal/Comment Not
performed
(70) ECG
(71) Audiogram
(72) Other
(80) Medical examiner’s recommendation:
Name of applicant: Date of birth:
____________________ _________________
□ Fit class ________ □ Medical certificate issued by undersigned (copy attached)
Signature: ______________________________ _______________
□ Unfit class __________ State reason:
□ Deferred for further evaluation. If yes, why and to whom?
(81) Comments, restrictions, limitations:
(82) Medical examiner’s declaration:
I hereby certify that I/my DME group have personally examined the applicant named on this medical examination report and that this report with any
attachment embodies my findings completely and correctly.
(83) Place and date:
Examiner’s Name and Address: (Block Capitals)
E-mail:
:
Examiner’s Stamp and number:
Telephone:
Telefax:
Medical Examiner’s signature:
Name and logo of
CIVIL AVIATION AUTHORITY
Adapted from Joint Aviation Authorities
INSTRUCTIONS FOR THE MEDICAL EXAMINER ON HOW TO COMPLETE THE MEDICAL EXAMINATION REPORT
FORM
All questions (boxes) on the Medical Examination Report Form must be completed in full.
Writing must be in BLOCK LETTERS with a black ball-point pen and must be legible. Exert sufficient pressure to make
legible copies. Completion of this form by typing/printing is both acceptable and preferable. If more space is required to
answer any question, write on a plain sheet of paper with the applicant’s name and birth date the additional information
required, followed by your signature and the date. The following instructions apply to the same numbered headings on the
Medical Examination Report Form.
NOTICE – Failure to complete the medical examination report form in full as required or to write legibly may result in
rejection of the application in total and may lead to withdrawal of any Medical Assessment issued. The making of false or
　
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