Appendix A Comprehensive Medical Examination Checklist
• "Substance dependence" is defined by any of the following: increased tolerance, withdrawal symptoms, impaired control of use, or continued use despite damage to health, or impairment of social, personal, or occupational functioning
• "Substance abuse" is defined as the following: use of an illegal substance, use of a substance or substances in situations in which such use is physically hazardous, or misuse of a substance when such misuse has impaired health or social or occupational functioning.
18. V. CONVICTION, AND/OR ADMINISTRATIVE ACTION HISTORY:
(1) Have you ever been convicted (which may include paying a fine or forfeiting bond or collateral) of an offense involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug;
(2) Have you ever been convicted, and/or subject to an administrative action by a state or other jurisdiction for an offense for which your driver's license was denied, suspended, cancelled, or revoked or which resulted in attendance at an educational or rehabilitation program? Individual traffic convictions are not required to be reported if they did not involve alcohol/drugs, suspension, revocation, cancellation, or denial of driving privileges, or attendance at an educational or rehabilitation program. If "Yes" is checked, you must give a description of the conviction(s) and/or administrative action(s) in theiadditional comments or explanation" box. The description must include:
The alcohol or drug offense for which you were arrested and/or convicted or the type of administrative action involved (e.g., attendance at an alcohol treatment program in lieu of conviction;
license denial, suspension, cancellation, or revocation for refusal to be tested; educational safe driving program for multiple speeding convictions, etc.);
The name of the state or other jurisdiction involved; and The date of the conviction(s) and/or administrative action(s). The FAA may check state motor vehicle driving licensing records to verify your responses.
18. W. HISTORY OF NON-TRAFFIC CONVICTIONS(S) (MISDEANORS OR FELONIES): Have you ever had any other (non-traffic) convictions (e.g., assault, battery, public intoxication, robbery, etc.)? If so, name the charge for which you were convicted and the date of conviction in the "additional comments or explanation" box.
List all visits in the last 3 years to a physician, physician assistant, nurse practitioner, psychologist, clinical social worker, or substance abuse specialist for treatment, examination, or medical/mental evaluation. List visits for counseling only if it was related to a personal substance abuse or psychiatric condition.
Enter the date of visit as month and year (e.g., 01/1990), name, address, and type of health professional consulted and briefly state reason for consultation. Repeat this process to add all relevant visits to medical professionals in the past 3 years. Multiple visits to one health professional for the same condition may be grouped together on one line. You do not need to
• Occasional common illnesses such as colds or sore throats that resolved;
Routine dental, eye, and FAA periodic medical examinations; or
• Consultations with your employer-sponsored employee assistance program (EAP) unless the consultations were for substance abuse or unless the consultations resulted in referral for psychiatric evaluation or treatment.
NOTE: After completing SECTION 2, carefully review and read the affirmation statements under the Airman's Signature and Declarations." If you agree with the statements, sign and date the document. Once you have completed, signed, and dated SECTION 2, you must provide ALL sections (SECTION 1-3) of this checklist to the state-licensed physician who will perform and complete the comprehensive medical examination, as required by Section 2307(a)(7) of FAA Extension, Safety, and Security Act of 2016 (FESSA).
4 FAA 8700-2 Comprehensive Medical Examination Checklist (04-17) A-4
Appendix A Comprehensive Medical Examination Checklist BASICMED SECTION 2: INDIVIDUAL INFORMATION (To be completed by the airman) Form approved OMB No: 2120-0770 Expires: 04/30/2020 1-2 Omitted Name: Last: First: Middle: 4 SS # (optional) Address/street: Telephone:
City State/Country Zip Code:
6. Date of birth: Country of Citizenship:
Color of hair: Color of eyes: Sex:
• Airline Transport • ATC Specialist • Commercial a Flight Engineer • Flight Instructor 10 Type of airman certificate(s) you hold: • Flight Navigator • Private • Recreational • Student • None
• Other 11 Occupation (optional): 12 Employer (optional):
Has your FAA Airman Medical 14. Omitted 13 suspended, revoked, or withdrawn? Certificate ever been denied, • No DYes If yes, give date MM/YYYY 15. Omitted 16 Date of Last FAA Medical Application MM/YYYY or • No Prior Application (If no prior application, STOP. You cannot use BasicMed.)
Do You Currently Use Any Medication? • No •Yes (If yes, list medication(s) and dosage used below.)
(Prescription or over-the-counter) Medication Name Dosage If additional space is needed, check this box • 17 and list information on an additional sheet of paper Do you ever use near vision contact • No •Yes Answer "Yes" if you wear a contact in one eye only to correct for near vision or if you have one 17b. contact that adjusts for near vision and one in the other eye that adjusts for distant vision.
ens(es) while flying Medical History: Mark "Yes" if you have or had any of the following conditions at ANY TIME in your life. Explain when it occurred, the severity, how it was treated, and if you are currently taking any medication or having treatment for the condition or have to see a physician for the condition. Discuss any "Yes" 18 responses with the physician doing this exam.
Additional comments or explanations (Give details in the space below) No Yes
a. Frequent or severe headaches:
b. Dizziness or fainting spell:
c. Unconsciousness for any reason:
d. Eye or vision trouble (except for glasses):
e. Hay fever or allergy:
f. Asthma or lung disease:
g. Heart or vascular trouble:
h. High or low blood pressure:
i. Stomach, liver, or intestinal trouble:
j. Kidney stone or blood in urine:
k. Diabetes:
I. Neurological disorders (epilepsy, seizures, stroke, paralysis, etc.):
No Yes FAA 8700-2 Comprehensive Medical Examination Checklist (04-17) A-5
Appendix A Comprehensive Medical Examination Checklist
m. Mental disorders of any sort (depression, anxiety, etc.):
n. or use of illegal substance in the last 2 years: Substance dependence, failed a drug test ever, or substance abuse O. Alcohol dependence or abuse:
p. Suicide attempt:
q. Motion sickness requiring medication:
r. Military medical discharge:
s. Medical rejection by military service:
t. Rejection for life or health insurance:
u. Admitted to a hospital:
x. Other illness, disability, or surgery:
History of (1) any conviction(s) involving driving while intoxicated by,
v. or (2) history of any convictions) or administrative action(s) involving while impaired by, or while under the influence of alcohol or a drug; 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. History of non-traffic conviction(s) (misdemeanors or felonies):
(e.g. battery, assault, public intoxication, robbery, etc.)
Any visits to a health professional Date Name Address Type of Provider Reason within the last 3 years?
19. | No _ Yes If "Yes, list the date, name, address, type of provider and why you saw them.
If additional space is needed, check this box • and list information on an additional sheet of paper Airman's Signature and Declarations In accordance with section 2307(b)(2) (A) of the FAA Extension, Safety, and Security Act of 2016 (Public Law 114-190), I affirm that:
• The answers provided by me on this checklist, including my answers regarding my medical history, are true and complete;
• I understand that I am prohibited under Federal Aviation Administration regulations from acting as pilot in command, or in any other capacity as a required flight crewmember, if I know or have reason to know of any medical deficiency or medically disqualifying condition that would make me unable to operate the aircraft in a safe manner; and
• I am aware of the regulations pertaining to the prohibition on operations during medical deficiency and I have no medically disqualifying conditions in accordance with applicable law.
Printed Name Airman Signature NOTE: You must provide ALL sections (SECTION 1-3) of this checklist to your state-licensed physician who will perform and complete the comprehensive medical examination as required by Section 2307(a)(7) of FESSA.
6 FAA 8700-2 Comprehensive Medical Examination Checklist (04-17) A-6
Appendix А BasicMed SECTION 3: Instructions for State-Licensed Physician Comprehensive Medical Examination Checklist This checklist is being submitted by an individual seeking to operate certain small aircraft in accordance with 14 CFR 61.113(i). This rule (BasicMed) allows pilots to use this checklist, and other requirements, in lieu of holding a FAA Airman Medical Certificate. The examination checklist may only be completed by a statelicensed physician. Under BasicMed, an individual may only act as pilot in command (PIC) of an aircraft that is authorized to carry not more than 6 occupants, and that has a maximum certificated takeoff weight of not more than 6,000 pounds.
As the examining physician, you are required to:
1. Review all sections of the checklist, particularly SECTION 2 completed by the airman.
2. Conduct a comprehensive medical examination in accordance with the checklist by:
a. Examining each item specified;
b. Exercising medical discretion, address, as medically appropriate, any medical conditions identified; and
c. Exercising medical discretion, determine whether any medical tests are warranted as part of the comprehensive medical examination.
3. Review and discuss all prescription and non-prescription medication(s) the individual reports taking and any potential to interfere with the safe operation of an aircraft or motor vehicle.
4. Complete the Physician's Signature and Declaration.
5. Complete the Physician's Information.
You should consider consulting available aeromedical resources on the flight hazards associated with medical conditions/medications, to include:
• The FAA Guide for Aviation Medical Examiners (AME Guide) at http://www.faa.gov/go/ameguide;
• The FAA Pharmaceuticals (Therapeutic Medications) Do Not Issue - Do Not Fly list at http://www.faa.gov/go/dni;
• Chapter 8 of the FAA's Aeronautical Information Manual (AIM 8-1-1), which addresses medical facts for pilots and is available at http://www.faa.gov/air traffic/publications/;
• www.taa.gov/go/basicmed.
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Appendix A Comprehensive Medical Examination Checklist BASICMED SECTION 3: MEDICAL EXAMINATION (To be performed by state-licensed physician only) Physician Use Only Patient/Pilot name:
Patient/Pilot Date of Birth: Examined
1. Head, face, neck and scalp:
2. Nose, sinuses, mouth, and throat:
3. Ears, general:
(Internal and external (canals) and eardrums (perforation):
4. Eyes (general), ophthalmoscopic, pupils, (equality and reaction), and ocular motility (associated parallel movement, nystagmus):
5. Lungs and chest:
(Not including breast examination):
6. Heart:
(precordial activity, rhythm, sounds, and murmurs):
7. Vascular system:
(pulse, amplitude, and character and arms, legs, and others):
8. Abdomen and viscera:
(including hernia):
9. Anus:
(not including digital examination):
10. Skin:
11. G-U system:
(not including pelvic examination):
12. Upper and lower extremities:
(strength and range of motion):
13. Spine and other musculoskeletal:
14. Identifying body marks, scars, and tattoos (size and location):
15. Lymphatics:
16. Neurologic:
(tendon reflexes, equilibrium, senses, cranial nerves, coordination, etc.):
17. Psychiatric:
(appearance, behavior, mood, communication, and memory):
18. General systemic:
19. Hearing:
20. Vision:
(distant, near, and intermediate vision, field of vision, color vision, and ocular alignment):
21. Blood pressure and pulse:
22. Anything else the physician, in his or her medical judgment, considers necessary.
8 FAA 8700-2 Comprehensive Medical Examination Checklist (04-17) A-8
Appendix A Comprehensive Medical Examination Checklist In accordance with 14 CFR 68.5 and 68.7, the examining physician is instructed to:
• Exercise medical discretion to address, as medically appropriate, any medical conditions identified, and to exercise medical discretion in determining whether any medical tests are warranted as part of the comprehensive medical examination; and
• Discuss all drugs the individual reports taking (prescription and nonprescription) and their potential to interfere with the safe operation of an aircraft or motor vehicle.
Physician's Signature and Declaration
• In accordance with section 2307(b)(2)(C)(iv), of the FAA Extension, Safety, and Security Act of 2016 (Public Law 114-190), I certify that I discussed all items on this checklist with the individual during my examination, discussed any medications the individual is taking that could interfere with their ability to safely operate an aircraft or motor vehicle, and performed an examination that included all of the items on this checklist. I certify that I am not aware of any medical condition that, as presently treated, could interfere with the individual's ability to sately operate an aircraft.
Patient/Pilot Name (printed) Patient/Pilot Date of Birth Signature of Physician who performed the exam Physician's Information Full name of physician who performed the Last : First: Middle Initial:
1. exam:
Printed or Stamp State license number: State Medical license number
2.
3. Telephone number:
Street address: Address: Suite:
4.
City: State: Zip Code:
Date of Examination:
5.
(MMIDDIYYYY) 9 FAA 8700-2 Comprehensive Medical Examination Checklist (04-17) A-9
Advisory Circular Feedback Form If you find an error in this AC, have recommendations for improving it, or have suggestions for new items/subjects to be added, you may let us know by contacting the General Aviation and Commercial Division (AFS-800) at 9-AFS-800-Correspondence@faa.gov or the Flight Standards Directives Management Officer at 9-AWA-AFS-140-Directives@faa.gov.
Subject: AC 68-1A, BasicMed Date: _____________________ Please check all appropriate line items:
An error (procedural or typographical) has been noted in paragraph ____________ on page _______.
Recommend paragraph _____________ on page __________ be changed as follows:
______________________________________________________________________ ______________________________________________________________________ In a future change to this AC, please cover the following subject:
(Briefly describe what you want added.)
______________________________________________________________________ ______________________________________________________________________ Other comments:
______________________________________________________________________ ______________________________________________________________________ I would like to discuss the above. Please contact me.
Submitted by: Date: ______________________