AMC1 ATCO.AR.F.020  Aero-medical forms

AERO-MEDICAL FORMS

The forms referred to in ATCO.AR.F.020 should reflect the information indicated in the following forms and corresponding instructions for completion.

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_{CIVIL AVIATION ADMINISTRATION/MEMBER STATE}

APPLICATION FORM FOR A MEDICAL CERTIFICATE

MEDICAL IN CONFIDENCE

Complete this page fully and in block capitals — Refer to instructions for completion.

General and medical history: Do you have, or have you ever had, any of the following? (Please tick). If yes, give details in the remarks section (30).

                                  Yes  No                                      Yes  No                                      Yes  No     Family history of:  Yes  No

INSTRUCTIONS FOR COMPLETION OF THE APPLICATION FORM FOR A MEDICAL CERTIFICATE

This application form and all attached report forms will be transmitted to the licensing authority. Medical confidentiality shall be respected at all times.

The applicant should personally complete, in full, all questions (sections) on the application form. Writing should be legible and in block capitals, using a ball-point pen. Completion of this form by typing/printing is also acceptable. If more space is required to answer any questions, a plain sheet of paper should be used, bearing the applicant’s name and signature, and the date of signing. The following numbered instructions apply to the numbered headings on the application form for a medical certificate.

Failure to complete the application form in full, or to write legibly, may result in non-acceptance of the application form. The making of false or misleading statements or the withholding of relevant information in respect of this application may result in criminal prosecution, denial of this application and/or withdrawal of any medical certificate(s) granted

AERO-MEDICAL EXAMINATION REPORT FORM FOR CLASS 1, CLASS 2 & CLASS 3 APPLICANTS

Clinical exam: Check each item           Normal  Abnormal                                                           Normal  Abnormal

Visual acuity

(229) Distant vision                                                              (236) Pulmonary function         (237) Haemoglobin

(249) AME declaration:

INSTRUCTIONS FOR COMPLETION OF THE AERO-MEDICAL EXAMINATION REPORT FORMS

The AME performing the aero-medical examination should verify the identity of the applicant.

All questions (sections) on the aero-medical examination report form should be completed in full. If an otorhinolaryngology examination report form is attached, then questions 209, 210, 211, and 234 may be omitted. If an ophthalmology examination report form is attached, then questions 212, 213, 214, 229, 230, 231, 232, and 233 may be omitted.

Writing should be legible and in block capitals using a ball-point pen. Completion of this form by typing/printing is also acceptable. If more space is required to answer any question, a plain sheet of paper should be used, bearing the applicant’s name, the AME’s name and signature, and the date of signing. The following numbered instructions apply to the numbered headings on the aero-medical examination report form.

Failure to complete the aero-medical examination report form in full, as required, or to write legibly, may result in non-acceptance of the application in total and may lead to withdrawal of any medical certificate issued. The making of false or misleading statements or the withholding of relevant information by an AME may result in criminal prosecution, denial of an application or withdrawal of any medical certificate(s) granted.

201      EXAMINATION CATEGORY — Tick appropriate box.

Initial — Initial examination for either class 1, 2 or 3; also initial examination for upgrading from class 2 to 1 (notate ‘upgrading’ in box 248).

Renewal/Revalidation —Subsequent ROUTINE examinations.

202      HEIGHT — Measure height, without shoes, in centimetres to nearest cm.

203      WEIGHT — Measure weight, in indoor clothes, in kilograms to nearest kg.

204      COLOUR EYE — State colour of applicant’s eyes from the following list: brown, blue, green, hazel, grey, multi.

205      COLOUR HAIR — State colour of applicant’s hair from the following list: brown, black, red, fair, bald.

206      BLOOD PRESSURE — Blood pressure readings should be recorded as Phase 1 for systolic pressure and Phase 5 for diastolic pressure. The applicant should be seated and rested. Recordings in mm Hg.

207      PULSE (RESTING) — The pulse rate should be recorded in beats per minute and the rhythm should be recorded as regular or irregular. Further comments if necessary may be written in section 228, 248 or separately.

208 to 227 inclusive constitute the general clinical examination, and each of the boxes should be marked (with a tick) as normal or abnormal.

208      HEAD, FACE, NECK, SCALP — To include appearance, range of neck and facial movements, symmetry, etc.

209      MOUTH, THROAT, TEETH, VOICE, SPEECH — To include voice and speech quality and appearance of buccal cavity, palate motility, tonsillar area, pharynx and also gums, teeth and tongue.

210      NOSE, SINUSES — To include appearance and any evidence of nasal obstruction or sinus tenderness on palpation.

211      EARS, DRUMS, EARDRUM MOTILITY — To include otoscopy of external ear, canal, tympanic membrane. Eardrum motility by valsalva manoeuvre or by pneumatic otoscopy.

212      EYES — ORBIT AND ADNEXA; VISUAL FIELDS — To include appearance, position and movement of eyes and their surrounding structures in general, including eyelids and conjunctiva. Visual fields check by campimetry, perimetry or confrontation.

213      EYES — PUPILS AND OPTIC FUNDI — To include appearance, size, reflexes, red reflex and fundoscopy. Special note of corneal scars.

214      EYES — OCULAR MOTILITY, NYSTAGMUS — To include range of movement of eyes in all directions; symmetry of movement of both eyes; ocular muscle balance; convergence; accommodation; signs of nystagmus.

215      LUNGS, CHEST, BREASTS — To include inspection of chest for deformities, operation scars, abnormality of respiratory movement, auscultation of breath sounds. Physical examination of female applicant’s breasts should only be performed with informed consent.

216      HEART — To include apical heartbeat, position, auscultation for murmurs, carotid bruits, palpation for trills.

217      VASCULAR SYSTEM — To include examination for varicose veins, character and feel of pulse, peripheral pulses, evidence of peripheral circulatory disease.

218      ABDOMEN, HERNIA, LIVER, SPLEEN — To include inspection of abdomen; palpation of internal organs; check for inquinal hernias in particular.

219      ANUS, RECTUM — Examination only with informed consent.

220      GENITO-URINARY SYSTEM — To include renal palpation; inspection palpation male/female reproductive organs only with informed consent.

221      ENDOCRINE SYSTEM — To include inspection, palpation for evidence of hormonal abnormalities/imbalance; thyroid gland.

222      UPPER AND LOWER LIMBS, JOINTS — To include full range of movements of joints and limbs, any deformities, weakness or loss. Evidence of arthritis.

223      SPINE, OTHER MUSCULOSKELETAL — To include range of movements, abnormalities of joints.

224      NEUROLOGIC — REFLEXES, ETC. To include reflexes, sensation, power, vestibular system — balance, romberg test, etc.

225      PSYCHIATRIC — To include appearance, appropriate mood/thought, unusual behaviour.

226      SKIN, IDENTIFYING MARKS AND LYMPHATICS — To include inspection of skin; inspection, palpation for lymphadenopathy, etc. Briefly describe scars, tattoos, birthmarks, etc., which could be used for identification purposes.

227      GENERAL SYSTEMIC — All other areas, systems and nutritional status.

228      NOTES — Any notes, comments or abnormalities to be described — extra notes if required on separate sheet of paper, signed and dated.

229      DISTANT VISION — Each eye to be examined separately and then both together. First without correction, then with spectacles (if used) and lastly with contact lenses, if used. Record visual acuity in appropriate boxes. Visual acuity to be tested with the appropriate chart for the distance.

230      INTERMEDIATE VISION — Each eye to be examined separately and then both together. First without correction, then with spectacles, if used, and lastly with contact lenses, if used. Record visual acuity in appropriate boxes (Yes/No).

231      NEAR VISION — Each eye to be examined separately and then both together. First without correction, then with spectacles if used and lastly with contact lenses, if used. Record visual acuity in appropriate boxes (Yes/No).

Note: Bifocal contact lenses and contact lenses correcting for near vision only are not acceptable.

232      SPECTACLES — Tick appropriate box signifying if spectacles are or are not worn by applicant. If used, state type of lens and frame and use-distance.

233      CONTACT LENSES — Tick appropriate box signifying if contact lenses are or are not worn. If worn, state type from the following list; hard, soft, gas-permeable or disposable.

313      COLOUR VISION — Tick appropriate box signifying if applicant is a normal trichromat or not. Indicate the colour vision testing methodology used and provide the results.

234      HEARING — Tick appropriate box to indicate hearing level ability as tested separately in each ear at 2 m.

235      URINALYSIS — State whether result of urinalysis is normal or not by ticking appropriate box. If no abnormal constituents, state NIL in each appropriate box.

236      PULMONARY FUNCTION — When required or on indication, state actual FEV1/FVC value obtained in % and state if normal or not with reference to height, age, sex and race.

237      HAEMOGLOBIN — Enter actual haemoglobin test result and state units used. Then state whether normal value or not, by ticking appropriate box.

238 to 244 inclusive: ACCOMPANYING REPORTS — One box opposite each of these sections must be ticked. If the test is not required and has not been performed, then tick the NOT PERFORMED box. If the test has been performed (whether required or on indication) complete the normal or abnormal box as appropriate. In the case of question 244, the number of other accompanying reports must be stated.

247      AME RECOMMENDATION — The applicant’s name, date of birth and reference number, should be entered here in block capitals. The applicable class of medical certificate should be indicated by a tick in the appropriate box. If a fit assessment is recommended and a medical certificate has been issued, this should be indicated in the appropriate box. An applicant may be recommended as fit for a lower class of medical certificate (e.g. class 2), but also be deferred or recommended as unfit for a higher class of medical certificate (e.g. class 1). If an unfit recommendation is made, applicable Part MED/Part ATCO.MED paragraph references should be entered. If an applicant is deferred for further evaluation, the reason and the specialist or licensing authority to whom the applicant is referred should be indicated.

248      COMMENTS, LIMITATIONS, ETC. — The AME’s findings and assessment of any abnormality in the history or examination, should be entered here. The AME should also state any limitation required.

249      AME DETAILS — The AME should sign the declaration, complete his/her name and address in block capitals, contact details and lastly stamp the relevant section with his/her designated AME stamp incorporating his/her AME number.

250      PLACE AND DATE — The place (town or city) and the date of the aero-medical examination should be entered here. The date of examination is the date of the general examination and not the date of finalisation of the form. If the aero-medical examination report is finalised on a different date, the date of finalisation should be entered in section 248 as ‘Report finalised on ...’.

OPHTHALMOLOGY EXAMINATION REPORT FORM

Complete this page fully and in block capitals — Refer to instructions for completion.

MEDICAL IN CONFIDENCE

Applicant’s details

Clinical examination                                                                        Visual acuity

(321) Ophthalmological remarks and recommendation:

(322) Examiner’s declaration:

INSTRUCTIONS FOR COMPLETION OF THE OPHTHALMOLOGY EXAMINATION REPORT FORM

Writing should be legible and in block capitals using a ball-point pen. Completion of this form by typing or printing is also acceptable. If more space is required to answer any question, a plain sheet of paper should be used, bearing the applicant’s name, the name and signature of the AME or ophthalmology specialist performing the examination and the date of signing. The following numbered instructions apply to the numbered headings on the ophthalmology examination report form.

Failure to complete the medical examination report form in full, as required, or to write legibly may result in non-acceptance of the application in total and may lead to withdrawal of any medical certificate issued. The making of false or misleading statements or the withholding of relevant information by an examiner may result in criminal prosecution, denial of an application or withdrawal of any medical certificate granted.

The AME or ophthalmology specialist performing the examination should verify the identity of the applicant. The applicant should then be requested to complete the sections 1, 2, 3, 4, 5, 6, 7, 12 and 13 on the form and then sign and date the consent to release of medical information (section 301) with the examiner countersigning as witness.

302      EXAMINATION CATEGORY — Tick appropriate box.

Initial — Initial examination for either class 1 or 2 or 3; also initial examination for upgrading from class 2 to 1 (notate ‘upgrading’ in section 303).

Renewal/Revalidation — Subsequent comprehensive ophthalmological examinations (due to refractive error).

Special referral — NON-ROUTINE examination for assessment of an ophthalmological symptom or finding.

303      OPHTHALMOLOGICAL HISTORY — Detail here any history of note or reasons for special referral.

304 to 309 inclusive: CLINICAL EXAMINATION — These sections together cover the general clinical examination and each of the sections should be marked (with a tick) as normal or abnormal. Any abnormal findings or comments on findings should be entered in section 321.

310      CONVERGENCE — Enter near point of convergence in cm, as measured using RAF near point rule or equivalent. Tick whether normal or abnormal. Any abnormal findings or comments on findings should be entered in section 321.

311      ACCOMMODATION — Enter measurement recorded in dioptres using RAF near point rule or equivalent. Tick whether normal or abnormal. Any abnormal findings or comments on findings should be entered in section 321.

312      OCULAR MUSCLE BALANCE — Ocular muscle balance is tested at distant 5 or 6 m and near at 30–50 cm and results recorded. Presence of tropia or phoria must be entered accordingly and also whether fusional reserve testing was NOT performed and if performed whether normal or not.

313      COLOUR VISION —Tick appropriate box signifying if applicant is a normal trichromat or not. Indicate the colour vision testing methodology used and provide results.

314–316 VISUAL ACUITY TESTING AT 5 m/6m, 1m and 30–50cm — Record actual visual acuity obtained in appropriate boxes. If correction not worn nor required, put line through corrected vision boxes. Distant visual acuity to be tested at either 5 m or 6 m with the appropriate chart for that distance.

317      REFRACTION — Record results of refraction. Indicate also whether for class 2 applicants, refraction details are based upon spectacle prescription.

318      SPECTACLES — Tick appropriate box signifying if spectacles are or are not worn by applicant. If used, state whether unifocal, bifocal, varifocal or look-over.

319      CONTACT LENSES — Tick appropriate box signifying if contact lenses are or are not worn. If worn, state type from the following list; hard, soft, gas-permeable, disposable.

320      INTRA-OCULAR PRESSURE — Enter intra-ocular pressure recorded for right and left eyes and indicate whether normal or not. Also indicate method used —applanation, air, etc.

321      OPHTHALMOLOGICAL REMARKS AND RECOMMENDATION — Enter here all remarks, abnormal findings and assessment results. Also enter any limitations recommended. If there is any doubt about findings or recommendations, the examiner may contact the medical assessor for advice before finalising the report form.

322      OPHTHALMOLOGY EXAMINER’S DETAILS — The ophthalmology examiner must sign the declaration, complete his/her name and address in block capitals, contact details and lastly stamp the report with his/her designated stamp incorporating his/her AME or specialist number.

323      PLACE AND DATE — Enter the place (town or city) and the date of examination. The date of examination is the date of the clinical examination and not the date of finalisation of form. If the ophthalmology examination report is finalised on a different date, enter date of finalisation on section 321 as ‘Report finalised on...’.

OTORHINOLARYNGOLOGY EXAMINATION REPORT FORM

Complete this page fully and in block capitals — Refer to instructions for completion.

MEDICAL IN CONFIDENCE

Applicant’s details

Clinical examination

INSTRUCTIONS FOR COMPLETION OF THE OTORHINOLARYNGOLOGY EXAMINATION REPORT FORM

Writing should be legible and in block capitals using a ball-point pen. Completion of this form by typing or printing is also acceptable. If more space is required to answer any question, a plain sheet of paper should be used, bearing the applicant’s name, the name and signature of the AME or otorhinolaryngology specialist performing the examination and the date of signing. The following numbered instructions apply to the numbered headings on the otorhinolaryngology examination report form.

Failure to complete the medical examination report form in full, as required, or to write legibly may result in non-acceptance of the application in total and may lead to withdrawal of any medical certificate issued. The making of false or misleading statements or the withholding of relevant information by an examiner may result in criminal prosecution, denial of an application or withdrawal of any medical certificate granted.

The AME or otorhinolaryngology specialist performing the examination should verify the identity of the applicant. The applicant should then be requested to complete the sections 1, 2, 3, 4, 5, 6, 7, 12 and 13 on the form and then sign and date the consent to release of medical information (section 401) with the examiner countersigning as witness.

402      EXAMINATION CATEGORY — Tick appropriate box.

Initial — Initial examination for class 1 or class 3; also initial examination for upgrading from class 2 to 1 or 3 (notate ‘upgrading’ in section 403).

Referral — NON-ROUTINE examination for assessment of an ORL symptom or finding.

403      OTORHINOLARYNGOLOGICAL HISTORY — Detail here any history of note or reasons for referral.

404–413 inclusive: CLINICAL EXAMINATION — These sections together cover the general clinical examination and each of the sections should be marked (with a tick) as normal or abnormal. Any abnormal findings or comments on findings should be entered in section 421.

414–418 inclusive: ADDITIONAL TESTING — These tests are only required to be performed if indicated by history or clinical findings and are not routinely required. For each test one of the boxes must be completed — if the test is not performed then tick that box — if the test has been performed then tick the appropriate box for a normal or abnormal result. All remarks and abnormal findings should be entered in section 421.

419      PURE TONE AUDIOMETRY — Complete figures for dB HL (hearing level) in each ear at all listed frequencies.

420      AUDIOGRAM — Complete audiogram from figures as listed in section 419.

421      OTORHINOLARYNGOLOGY REMARKS AND RECOMMENDATION — Enter here all remarks, abnormal findings and assessment results. Also enter any limitations recommended. If there is any doubt about findings or recommendations the examiner may contact the medical assessor for advice before finalising the report form.

422      OTORHINOLARYNGOLOGY EXAMINER’S DETAILS — The otorhinolaryngology examiner must sign the declaration, complete his/her name and address in block capitals, contact details and lastly stamp the report with his/her designated stamp incorporating his/her AME or specialist number.

423      PLACE AND DATE — Enter the place (town or city) and the date of examination. The date of examination is the date of the clinical examination and not the date of finalisation of form. If the ORL examination report is finalised on a different date, enter date of finalisation in section 421 as ‘Report finalised on...’.