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.
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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.
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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: ______________________