548 Application For Medical Certificate

CAAP application form for medical certificate

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APPLICATION FOR

MEDICAL CERTIFICATE

A. APPLICATION IS HEREBY MADE FOR ISSUANCE OF THE FOLLOWING AVIATION MEDICAL CERTIFICATE:

1.

2.

CLASS 1

B. AIRMAN PERSONAL INFORMATION:
1. NAME (Last ---------------------- First------------------------- Middle)

3.

CLASS 2

CLASS 3

5. PERMANENT ADDRESS (Street or PO Box Number)

2. TELEPHONE:
3. FAX NUMBER:
4. EMAIL ADDRESS:
7. HEIGHT

6. CITY

8. WEIGHT

9. HAIR

10. EYES

ISLAND/STATE/PROVINCE

11. SEX

DAY

5. DATE LAST MEDICAL

/
DAY

/
MONTH

YEAR

4. AVIATION EMPLOYER

8. FOR CAAP USE

6. HAS YOUR AVIATION MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED OR REVOKED?

/
MONTH

3. TOTAL LAST 6 MONTHS

YES (PROVIDE EXPLANATION)

(a)

YEAR

If yes, give date:

NO

(b)

/
DAY

7. EXPLANATION FOR DENIAL

COUNTRY
13. FOR CAAP USE

12. DATE OF BIRTH

/
C. PEL LICENSE AND MEDICAL INFORMATION:
1. -PEL LICENSE #
2. TOTAL FLT HRS

MAIL CODE

/
MONTH

YEAR

:

SUSPENSION OR REVOCATION
D. MEDICAL HISTORY:
HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING? Answer “Yes” or “No” for every
condition listed below. In the EXPLANATIONS box below, you may note “PREVIOUSLY REPORTED, NO CHANGE” only if the explanation of the condition was reported
on a previous application for an airman medical certificate and there has been no change in your condition. (See instructions for completion):
1.

YES

NO

CONDITION:
Frequent or severe headaches?

13.

2.
3.

YES

NO

CONDITION:
Neurological disorders, epilepsy, seizures, stroke, paralysis, etc

Dizziness or fainting spell?

14.

Mental disorders of any sort, depression, anxiety, etc

Unconsciousness for any reason?

15.

Motion sickness requiring medication?

4.

Eye or vision trouble except for glasses?

16.

Medical discharge from any organization?

5.

Hay fever or allergy?

17.

Medical rejection by any organization?

6.

Asthma or lung disease?

18.

Rejection for life or medical insurance?

7.

Heart or vascular trouble or HIV?

19.

Admission to hospital?

8.

High or low blood pressure?

20.

Alcohol dependence or abuse?

9.

Stomach, liver, or intestinal trouble?

21.

Substance dependence, or substance abuse, or use of illegal
substances in the last 2 years, or failed a drug test ever?

10.

Kidney stone or blood in the urine?

22.

11.

Suicide attempt?

23.

12.

Diabetes or sugar in urine

Other illness disability or surgery? (attach report)
Near vision contact lenses?

24. EXPLANATIONS:

25. FOR CAAP USE

E. VISITS TO THE HEALTH PROFESSIONAL WITHIN LAST 3 YEARS?
Date

(a)

F. USE OF MEDICATION? (Daily or Regular Use: Non-Prescription or Prescription)

(a)

NO
(b)

NO

Reason

(a)

G. CONVICTION AND/OR ADMINISTRATIVE HISTORY:
History of (1) any conviction(s) involving driving while intoxicated by, while impaired by, or while under the
1.

YES

YES (Explain Below) (b)

Name, Address & Type of Health Professional Consulted

influence of alcohol or a drug; or (2) history of any conviction(s) or administrative action(s) involving an
offense(s) which resulted in denial, suspension, cancellation or revocation of driving privileges or which
resulted in attendance at an educational or rehabilitation program?

YES (List Below)

(b)

2.

YES
(a)

NO
(b)

NO

History of nontraffic
conviction(s)?
(misdemeanors or felonies)
3. FOR CAAP USE

H. CERTIFICATION – I hereby represent that the information entered in this application is true and correct.
A person shall not with intent to deceive: or make any false
1. DATE
2. APPLICANT SIGNATURE :
representation for the purpose of procuring for himself or any other
person the grant, issue, renewal or variation of any such certificate...
CAAP Form 548 [0]2011)

Page 1 of 2.

REPORT OF MEDICAL EXAMINATION
I. GENERAL EXAMINATION:
1. Height (inches)

2. Weight (pounds)

3. Statement of Demonstrated Ability

YES

(a)
Normal

Abnormal

4.
5.
6.

NO

(b)

DEFECT NOTED?

Normal

CONDITION:
Head, face, neck and scalp?

Abnormal

16

CONDITION:
Vascular system (Pulse, amplitude & character, arms, legs, other

Nose?

17

Abdomen and viscera (including hernia)

Sinuses?

18.

Anus (not including digital examination)

7.

Mouth and throat?

19.

Skin

8.

Ears (General)

20.

G.U. system (not including pelvic examination)

9.

Ear Drums (perforation)

21.

Upper and lower extremities (strength and range of motion)

10.

Eyes (General)

22.

Spine, other musculoskeletal

11

Ophthalmoscopic

23.

Identifying body marks, scars, tattoos (size and location)

12.

Pupils (Equality and Reaction)

24.

Lymphatics

13.

Ocular motility (associated parallel movement,

25.

Neurologic (tendon reflexes, equilibrium, cranial nerves, coordination, etc.)

14.

Lungs and Chest (not including breast exam)

26.

Psychiatric (appearance, behavior, mood, communication & memory)

15.

Heart (precordial activity, rhythm, sounds & murmurs)

27.

General Systemic

28. NOTES: (Describe every abnormality in detail. Enter applicable item number before each comment. Use additional sheets if necessary and attach to this form.

J. HEARING:
1. Conversational

2. Record AudIometric
Speech Discrimination score
below

Voice Test (at 6 feet)

3. Right Ear
Audiometer

Pass
Fail

(a)
(b)

500

Threshold in
decibels

K. VISION:
1. Distant Vision

a. Right= 20/
b. Left= 20/
c. Both= 20/

(a)

1000
(b)

2000
(c)

2. Near Vision

Corr. to 20/
Corr. to 20/
Corr. to 20/

a. Right= 20/
b. Left= 20/
c. Both= 20/

L. HETEROPHORIA (in prism diopters):

4. Left Ear
3000

4000

(d)

500

(e)

(a)

3. Intermediate Vision

Corr. to 20/
Corr. to 20/
Corr. to 20/

a. Right= 20/
b. Left= 20/
c. Both= 20/

ESO

Corr. to 20/
Corr. to 20/
Corr. to 20/

EXO

1000

2000

(b)

3000

(c)

(d)

4. Color Vision
Test Used __________

4000
(e)

5. Visual Acuity

Pass
Fail

(a)
(b)

R.H

L.H

M. CARDIOVASCULAR:

1. Blood Pressure

(a) Systolic:

(b) Diastolic:

2. Pulse (Sitting):

3. ECG (Date):

N. URINALYSIS:

1.

Normal

2.

Abnormal

3. Albumin

(SPECIFY)

4. Sugar

(SPECIFY)

O. DRUG SCREENING (Commercial and Airline Transport Pilots):

1. Methamphetamine

a.

b.

NEGATIVE

2. Cannabinoids

POSITIVE

a.

NEGATIVE

b.

POSITIVE

P. COMMENTS ON HISTORY AND FINDINGS: AME shall comment on all "YES" answers in the Medical History section and for abnormal findings of the examination.
(Attach all consultation reports, ECGs, X-rays, etc. to this report before mailing.

1. Significant Medical History?

(a)

YES

(b)

2. Abnormal Physical Findings?

NO

(a)

YES

(b)

NO

Q. MEDICAL EXAMINER'S ANALYSIS AND DECLARATION:
ISSUANCE RECOMMENDED

1.

2.

ISSUANCE NOT RECOMMENDED

3. DISQUALIFYING DEFECTS: (List by section letter and item number or enter the word "None")

4. I hereby certify that I have personally reviewed the medical history and personally examined the applicant named on this medical examination report. This
report with any attachments embodies my findings completely and correctly:
5. Date of Examination
6. AME SERIAL NUMBER
8. AME PRINTED NAME
10. FOR CAAP USE:

/
DAY

/
MONTH

YEAR

7. AME TELEPHONE #

CAAP Form 548 [0]2011

9. AME SIGNATURE

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