GM1 ARA.MED.135(b);(c) Aero-medical forms

OPHTHALMOLOGY AND OTORHINOLARYNGOLOGY EXAMINATION REPORT FORMS

The ophthalmology and otorhinolaryngology examination report forms may be used as indicated in the following forms and corresponding instructions for completion.

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; 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 PERCEPTION – Enter type of pseudo-isochromatic plates (ishihara) as well as number of plates presented with number of errors made by examinee. State whether advanced colour perception testing is indicated and what methods used (which colour lantern or anomaloscopy) and finally whether judged to be colour safe or unsafe. Advanced colour perception testing is usually only required for initial assessment, unless indicated by change in applicant’s colour perception.

314–316 VISUAL ACUITY TESTING AT 5 m/6 m, 1 m and 30-50 cm – 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 AMS 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; also initial examination for upgrading from class 2 to 1 (notate upgrading’ in section 403)

Special Referral – NON-ROUTINE examination for assessment of an ORL symptom or finding

403       OTORHINOLARYNGOLOGICAL HISTORY – Detail here any history of note or reasons for special 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 AMS 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 ........’.