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ticking Yes or No.
70–72 ACCOMPANYING REPORTS – One box opposite each of these sections must be ticked. If the test is not required
and has not been performed, then tick the NOT PERFORMED box. If the test has been performed (whether required or on
indication) complete the normal or abnormal box as appropriate. In the case of question 72, the number of other
accompanying reports must be stated.
80 MEDICAL EXAMINER’S RECOMMENDATION – Enter name of applicant in block capitals and then tick appropriate
box with applicable class of Medical Assessment. If a fit assessment is recommended, indicate whether a Medical Certificate
has been issued or not. An applicant may be recommended as Fit for Class 2 but also deferred or recommended as Unfit for
Class 1. If an Unfit recommendation is made, the reason must be stated. If an applicant is deferred for further evaluation,
indicate the reason and the doctor to whom the applicant is referred.
81 COMMENTS, RESTRICTIONS, LIMITATIONS, ETC. – Enter here your findings and assessment of any abnormality
in the history or examination. State also any limitation required.
82 MEDICAL EXAMINERS DETAILS – In this section the DME must sign the declaration, complete his name and
address in block capitals, contact telephone number and e-mail address (and fax number if available) and lastly stamp the
relevant box with his designated medical examiner’s stamp incorporating his examiner’s number.
283 PLACE AND DATE – Enter the place (town or city) and the date of examination. The date of examination is the date
of the general examination and not the date of finalisation of form. If the medical examination report is finalised on a different
date, enter date of finalisation in Section 81 as “Report finalised on ... .”
APPLICATION FORM FOR AN AVIATION MEDICAL ASSESSMENT
Complete this page fully using a black ball point pen and in block letters – see instruction page for details MEDICAL IN CONFIDENCE
(1) Surname: (2) Previous surname(s):
(3) National Identification Number (if
applicable):
(4) Forename(s): (5) Date of birth: (6) Sex
Male □
Female □
(7) Application
Initial □
Renewal □
(8) Country of licence issue: (9) Class of Medical Assessment applied for:
1st □ 2nd □ 3rd □ Other □
(10) Type of licence applied for (if
initial application):
(11) Place and country of birth: (12) Nationality: (13) Occupation (principal)
(14) Permanent address:
Postcode:
Country:
Telephone:
Mobile/Cell:
E-mail: @
(15) Postal address (if different)
Postcode:
Country:
Telephone:
(16) Employer (principal)
(17) Last medical examination
Date:
Place:
(18) Aviation licence(s) held (type):
Licence number(s):
Country(ies) of issue:
(19) Family Physician’s Name and Address:
e-mail:
Telephone:
(20) Any Limitations on Licence/Medical Assessment?
No □ Yes □
Details:
(21) Have you ever had an aviation Medical Assessment denied, suspended or
revoked by any licensing authority? If yes, discuss with the medical examiner
No □ Yes □ Date: Place:
Details:
(22) Total flight time (hours): (23) Flight time (hours)
since last medical:
(24) Aircraft currently flown (e.g. Boeing 737, Cessna 150 etc):
(25) Any aircraft accident or reported incident since last medical?
No □ Yes □ Date: Place:
Details:
(26) Type of flying intended (1) e.g. commercial air
transport, flying instruction, private:
(27) Type of flying intended (2):
Single-crew □ Multi-crew □
(28) Do you drink alcoholic beverages? No □ Yes □
If YES, state average weekly intake in units:
(30) Do you currently use any medication, including non-prescribed medication?
Yes □ No □
If YES, state name of medication, date commenced, daily or weekly dose, and
cause (diagnosis):
(29) Do you smoke tobacco products?
Never □
Previously □ Date of cessation:
Currently □ State type, amount & number of years:
PLEASE TURN OVER
Name and Logo of Civil
Aviation Authority Adapted from Joint Aviation Authorities
(31) General and medical history: Do you have, or have you ever had, any of the following? YES or NO must be ticked after each question.
Elaborate YES answers in the remarks section and discuss them with the medical examiner.
Yes No Yes No Yes No Yes No
101 Eye disorders/eye
surgery
112 Nose or throat disease
or speech disorder
123 Malaria or other tropical
disease
Family history of:
102 Spectacles and/or
contact lenses ever worn
113 Head injury or
　
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