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:
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______________________________________________________________________ ______________________________________________________________________ Other comments:
______________________________________________________________________ ______________________________________________________________________ I would like to discuss the above. Please contact me.
Submitted by: Date: ______________________