Aviation Pilot Medical History Questionnaire
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Aviation Pilot Medical History Questionnaire
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This aviation pilot medical history questionnaire provides a thorough documentation system for pilots and aviators undergoing Federal Aviation Administration (FAA) medical certification examinations. The form collects detailed information about past and current medical conditions, medications, surgeries, hospitalizations, and aviation-specific health concerns that may affect flight safety and medical certificate eligibility for first, second, or third class airman medical certificates.
Designed for Aviation Medical Examiners (AMEs), aerospace medicine clinics, flight school medical departments, and FAA-designated physician offices, this form includes fields for cardiovascular history, neurological conditions, vision and hearing status, mental health screening, substance use history, and medication declarations. It addresses FAA-reportable conditions, previous medical certificate denials or revocations, special issuance requirements, and ensures compliance with 14 CFR Part 67 medical standards, facilitating accurate MedXPress submission and streamlined certification processing.
What's included
- Pilot demographics and certificate type
- Complete medication list and dosages
- Known allergies and reactions
- Cardiovascular disease history
- Neurological and psychiatric conditions
- Vision and hearing status
- Substance use and alcohol history
- Previous surgeries and hospitalizations
- FAA-reportable medical conditions
- Previous certificate denials or special issuances
- Family medical history relevant to flight safety
Who uses this template
- Aviation Medical Examiners
- Aerospace Medicine Clinics
- Flight School Medical Departments
- FAA-Designated Physician Offices
- Corporate Aviation Health Services
All form fields
10 fields across 3 pages. Customize any field after signing up.
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