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548 Application For Medical Certificate
CAAP application form for medical certificate
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: INSTRUCTIONS
Print or type. Do not write in shaded areas. These are for CAAP use
only. Submit original only to the CAAP or a CAAP Authorized Person.
If additional space is required, use an attachment
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
Page 2 of 2.
