AMC1 ARA.MED.135(b);(c) Aero-medical forms

MEDICAL EXAMINATION REPORT FORMS

The forms referred to in ARA.MED.135(b) and (c) should reflect the information indicated in the following forms and corresponding instructions for completion.

MEDICAL EXAMINATION REPORT FORM FOR CLASS 1 & CLASS 2 APPLICANTS

MEDICAL IN CONFIDENCE

Clinical exam: Check each item                          Normal      Abnormal                                                                                            Normal      Abnormal

Visual acuity                                                                        

(229) Distant vision at 5m/6m                                                                        (236) Pulmonary function              (237) Haemoglobin

(249) AME declaration:

Shaded areas do not require completion

MEDICAL EXAMINATION REPORT FORM FOR LAPL APPLICANTS

MEDICAL IN CONFIDENCE

Clinical exam: Check each item                          Normal      Abnormal                                                                                            Normal      Abnormal

Visual acuity                                                                        

(229) Distant vision at 5m/6m                                                                        (236) Pulmonary function              (237) Haemoglobin

(249) AME/GMP declaration:

INSTRUCTIONS FOR COMPLETION OF THE MEDICAL EXAMINATION REPORT FORMS

The AME performing the examination should verify the identity of the applicant.

All questions (sections) on the 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 medical 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 AME may result in criminal prosecution, denial of an application or withdrawal of any medical certificate(s) granted.

Shaded areas do not require completion for the medical examination report form for the LAPL.

201       EXAMINATION CATEGORY – Tick appropriate box.

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

Renewal/Revalidation – Subsequent ROUTINE examinations.

Extended Renewal/Revalidation – Subsequent ROUTINE examinations, which include comprehensive ophthalmological and otorhinolaryngology 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 – To include 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 AT 5/6 METRES – 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 at either 5 or 6 metres with the appropriate chart for the distance.

230       INTERMEDIATE VISION AT 100 CM – 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 as ability to read N14 at 100 cm (Yes/No).

231       NEAR VISION AT 30-50 CM. – 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 as ability to read N5 at 30-50 cm (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 whether unifocal, bifocal, varifocal or look-over.

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 PERCEPTION – Tick appropriate box signifying if colour perception is normal or not. If abnormal; state number of plates of the first 15 of the pseudo-isochromatic plates (Ishihara 24 plates) have not been read correctly.

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 paragraph references should be entered. If an applicant is deferred for further evaluation, the reason and the doctor 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. The GMP identification no. is the number provided by the national medical system.

250       PLACE AND DATE – The place (town or city) and the date of 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 medical examination report is finalised on a different date, the date of finalisation should be entered in section 248 as ‘Report finalised on .......’.