Aviation Medical Exam Clinical History Form

This aviation-specific clinical history form is designed to streamline the FAA medical certification process for Aviation Medical Examiners and pilots seeking first, second, or third class medical certificates. The form addresses all health areas scrutinized by the Federal Aviation Administration including cardiovascular conditions, neurological disorders, mental health history, substance use, vision and hearing status, and medications that may affect flight safety. It includes specific questions about conditions that may be disqualifying or require special issuance authorization.

The template guides pilots through comprehensive disclosure requirements including prior medical certificate denials, suspensions, or revocations, history of loss of consciousness, seizures, diabetes management, cardiac events, psychiatric treatment, and substance abuse. It captures current medication lists with specific attention to psychoactive drugs, anticonvulsants, and other FAA-restricted medications. The form also documents any prior special issuance authorizations, required ongoing monitoring, and aviation incident or accident history. This comprehensive approach ensures Aviation Medical Examiners have complete information necessary for certification decisions while helping pilots prepare required documentation in advance of their examination.