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GM1 ARA.MED.135(b)

Available versions for ERULES-1963177438-12228

ED Decision 2012/006/R found in: Aircrew (No 1178/2011) Part-FCL Part-MED Part-CC Part-ARA Part-ORA Part-DTO (Aug 2023)

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

ED Decision 2012/006/R

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**

<table border="1" cellpadding="0" cellspacing="0" width="603"><tr><td valign="top" width="222">(1) State applied to:</td><td colspan="3" valign="top" width="382">(2) Medical certificate applied for: class 1  class 2 </td></tr><tr><td valign="top" width="222">(3) Surname:</td><td colspan="2" valign="top" width="222">(4) Previous surname(s):</td><td valign="top" width="160">(12) Application: Initial  Revalidation/Renewal </td></tr><tr><td valign="top" width="222">(5) Forename(s):</td><td valign="top" width="152">(6) Date of birth:</td><td valign="top" width="70">(7) Sex: Male Female </td><td valign="top" width="160">(13) Reference number:</td></tr><tr><td colspan="4" valign="top" width="603"><v:rect filled="f" id="Rectangle_x0020_19" o:allowincell="f" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 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Medical confidentiality will be respected at all times.---------------------------------------- --------------------------------------------------------------- --------------------------------------------------------------- Date Signature of applicant Signature of AME</td></tr><tr height="0"></tr></table>

<table border="1" cellpadding="0" cellspacing="0" width="603"><tr><td valign="top" width="158">(302) Examination category:</td><td valign="top" width="445">(303) Ophthalmological history:</td></tr><tr><td valign="top" width="158"> Initial </td><td valign="top" width="445"></td></tr><tr><td valign="top" width="158"> Revalidation </td><td valign="top" width="445"></td></tr><tr><td valign="top" width="158"> Renewal </td><td valign="top" width="445"></td></tr><tr><td valign="top" width="158"> Special referral </td><td valign="top" width="445"></td></tr></table>

**Clinical examination****Visual acuity**

<table border="1" cellpadding="0" cellspacing="0" width="604"><tr><td colspan="4" valign="top" width="170">Check each item</td><td width="51">Normal</td><td width="59">Abnormal</td><td valign="top" width="20"></td><td colspan="6" valign="top" width="185">(314) Distant vision at 5m/6m Uncorrected</td><td colspan="2" valign="top" width="64">Spectacles</td><td colspan="2" valign="top" width="56">Contact lenses</td></tr><tr><td colspan="4" valign="top" width="170">(304) Eyes, external &amp; eyelids</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Right eye</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="4" valign="top" width="170">(305) Eyes, Exterior</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Left eye</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="4" valign="top" width="170"> (slit lamp, ophth.)</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Both eyes</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="4" valign="top" width="170">(306) Eye position and movements</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td colspan="6" valign="top" width="185">(315) Intermediate vision at 1m Uncorrected</td><td colspan="2" valign="top" width="64">Spectacles</td><td colspan="2" valign="top" width="56">Contact lenses</td></tr><tr><td colspan="4" valign="top" width="170">(307) Visual fields (confrontation)</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Right eye</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="4" valign="top" width="170">(308) Pupillary reflexes</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Left eye</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="4" valign="top" width="170">(309) Fundi (Ophthalmoscopy)</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Both eyes</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td valign="top" width="121">(310) Convergence</td><td colspan="3" valign="top" width="50">cm</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td colspan="6" valign="top" width="185">(316) Near vision at 30-50cm Uncorrected</td><td colspan="2" valign="top" width="64">Spectacles</td><td colspan="2" valign="top" width="56">Contact lenses</td></tr><tr><td valign="top" width="121">(311) Accommodation</td><td colspan="3" valign="top" width="50">D</td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Right eye</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="4" valign="top" width="170"></td><td valign="top" width="51"></td><td valign="top" width="59"></td><td valign="top" width="20"></td><td valign="top" width="58">Left eye</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="6" valign="top" width="280">(312) Ocular muscle balance (in prisme dioptres) </td><td valign="top" width="20"></td><td valign="top" width="58">Both eyes</td><td colspan="2" valign="top" width="57"></td><td colspan="3" valign="top" width="70">Corrected to</td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="2" valign="top" width="137">Distant at 5m/6m</td><td colspan="4" valign="top" width="143">Near at 30-50 cm</td><td valign="top" width="20"></td><td colspan="2" valign="top" width="86"></td><td colspan="4" valign="top" width="99"></td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="2" valign="top" width="137">Ortho</td><td colspan="4" valign="top" width="143">Ortho</td><td valign="top" width="20"></td><td colspan="2" valign="top" width="86">(317) Refraction</td><td colspan="2" width="49">Sph</td><td colspan="2" width="50">Cylinder</td><td width="58">Axis</td><td colspan="3" width="62">Near (add)</td></tr><tr><td colspan="2" valign="top" width="137">Eso</td><td colspan="4" valign="top" width="143">Eso</td><td valign="top" width="20"></td><td colspan="2" valign="top" width="86">Right eye</td><td colspan="4" valign="top" width="99"></td><td valign="top" width="58"></td><td colspan="3" valign="top" width="62"></td></tr><tr><td colspan="2" valign="top" width="137">Exo</td><td colspan="4" valign="top" width="143">Exo</td><td valign="top" width="20"></td><td colspan="2" valign="top" width="86">Left eye</td><td colspan="4" valign="top" width="99"></td><td valign="top" width="58"></td><td colspan="3" valign="top" width="62"></td></tr><tr><td colspan="2" valign="top" width="137">Hyper</td><td colspan="4" valign="top" width="143">Hyper</td><td valign="top" width="20"></td><td colspan="10" valign="top" width="304">Actual refraction examined Spectacles prescription based </td></tr><tr><td colspan="2" valign="top" width="137">Cyclo</td><td colspan="4" valign="top" width="143">Cyclo</td><td valign="top" width="20"></td><td colspan="2" valign="top" width="86"></td><td colspan="4" valign="top" width="99"></td><td colspan="3" valign="top" width="64"></td><td valign="top" width="55"></td></tr><tr><td colspan="6" valign="top" width="280">Tropia Yes No Phoria Yes No </td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145">(318) Spectacles </td><td colspan="5" valign="top" width="160">(319) Contact lenses</td></tr><tr><td colspan="6" valign="top" width="280">Fusional reserve testing Not performed Normal Abnormal</td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145">Yes  No  </td><td colspan="5" valign="top" width="160">Yes  No  </td></tr><tr><td colspan="6" valign="top" width="280">(313) Colour perception</td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145">Type:</td><td colspan="5" valign="top" width="160">Type:</td></tr><tr><td colspan="3" valign="top" width="142">Pseudo-Isochromatic plates</td><td colspan="3" valign="top" width="138">Type: Ishihara (24 plates)</td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145"></td><td colspan="5" valign="top" width="160"></td></tr><tr><td colspan="3" valign="top" width="142">No of plates: </td><td colspan="2" valign="top" width="79">No of errors:</td><td valign="top" width="59"></td><td valign="top" width="20"></td><td colspan="10" valign="top" width="304">(320) Intra-ocular pressure</td></tr><tr><td colspan="6" valign="top" width="280">Advanced colour perception testing indicated Yes No </td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145">Right (mmHg)</td><td colspan="5" valign="top" width="160">Left (mmHg)</td></tr><tr><td colspan="6" valign="top" width="280">Method:</td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145"></td><td colspan="5" valign="top" width="160"></td></tr><tr><td colspan="6" valign="top" width="280">Colour SAFE Colour UNSAFE</td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145">Method</td><td colspan="5" valign="top" width="160">Normal  Abnormal </td></tr><tr><td colspan="6" valign="top" width="280"></td><td valign="top" width="20"></td><td colspan="5" valign="top" width="145"></td><td colspan="5" valign="top" width="160"></td></tr><tr height="0"></tr></table>

(321) **Ophthalmological remarks and recommendation:**

(322) **Examiner’s declaration:**

<table border="1" cellpadding="0" cellspacing="0" width="603"><tr><td colspan="3" valign="top" width="603">I hereby certify that I/my AME group have personally examined the applicant named on this medical examination report and that this report with any attachment embodies my findings completely and correctly.</td></tr><tr><td valign="top" width="192">(323) Place and date:</td><td valign="top" width="245">Ophth examiner’s name and address: (block capitals)</td><td valign="top" width="166">AME or specialist stamp with No.:</td></tr><tr><td valign="top" width="192">AME signature:</td><td valign="top" width="245">E-mail:Telephone No.:Telefax No.:</td><td valign="top" width="166"></td></tr></table>

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**

<table border="1" cellpadding="0" cellspacing="0" width="603"><tr><td valign="top" width="217">(1) State applied to:</td><td colspan="3" valign="top" width="386">(2) Medical certificate applied for: class 1  class 2 </td></tr><tr><td valign="top" width="217">(3) Surname:</td><td colspan="2" valign="top" width="234">(4) Previous surname(s):</td><td valign="top" width="152">(12) Application: Initial  Revalidation/Renewal </td></tr><tr><td valign="top" width="217">(5) Forename(s):</td><td valign="top" width="165">(6) Date of birth:</td><td valign="top" width="69">(7) Sex: Male Female </td><td valign="top" width="152">(13) Reference number:</td></tr><tr><td colspan="4" valign="top" width="603">(401) Consent to release of medical information: I hereby authorise the release of all information contained in this report and any or all attachments to the AME and, where necessary, to the medical assessor of the licensing authority, recognising that these documents, or any electronically stored data, are to be used for completion of a medical assessment and will become and remain the property of the licensing authority, providing that I or my physician may have access to them according to national law. Medical confidentiality will be respected at all times.--------------------------------------- -------------------------------------------------------------- -------------------------------------------------------------- Date Signature of applicant Signature of AME</td></tr><tr height="0"></tr></table>

<table border="1" cellpadding="0" cellspacing="0" width="603"><tr><td valign="top" width="158">(402) Examination category:</td><td valign="top" width="445">(403) Otorhinolaryngological history:</td></tr><tr><td valign="top" width="158"></td><td valign="top" width="445"></td></tr><tr><td valign="top" width="158"> Initial </td><td valign="top" width="445"></td></tr><tr><td valign="top" width="158"> Special referral </td><td valign="top" width="445"></td></tr><tr><td valign="top" width="158"></td><td valign="top" width="445"></td></tr></table>

**Clinical examination**

<table border="1" cellpadding="0" cellspacing="0" width="604"><tr><td colspan="2" valign="top" width="221">Check each item</td><td colspan="3" valign="top" width="58">Normal</td><td valign="top" width="58">Abnormal</td><td valign="top" width="18"></td><td colspan="12" valign="top" width="249">(419) Pure tone audiometry</td></tr><tr><td colspan="2" valign="top" width="221">(404) Head, face, neck, scalp</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="12" valign="top" width="249">dB HL (hearing level)</td></tr><tr><td colspan="2" valign="top" width="221">(405) Buccal cavity, teeth</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" valign="top" width="53">Hz</td><td colspan="6" valign="top" width="104">Right ear</td><td colspan="4" valign="top" width="92">Left ear</td></tr><tr><td colspan="2" valign="top" width="221">(406) Pharynx</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">250</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(407) Nasal passages and naso-pharynnx</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">500</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221"> (incl. anterior rhinoscopy)</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">1000</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(408) Vestibular system incl. Romberg test</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">2000</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(409) Speech</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">3000</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(410) Sinuses</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">4000</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(411) Ext acoustic meati, tympanic membranes</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">6000</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(412) Pneumatic otoscopy</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" width="53">8000</td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221">(413) Impedance tympanometry including</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="2" valign="top" width="53"></td><td colspan="6" valign="top" width="104"></td><td colspan="4" valign="top" width="92"></td></tr><tr><td colspan="2" valign="top" width="221"> Valsalva menoeuvre (initial only)</td><td colspan="3" valign="top" width="58"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td colspan="12" valign="top" width="249">(420) Audiogram</td></tr><tr><td colspan="2" valign="top" width="221"></td><td colspan="2" valign="top" width="19"></td><td valign="top" width="39"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td valign="top" width="42"></td><td colspan="3" valign="top" width="31"></td><td colspan="8" valign="top" width="176">o = Right – – – = Air x = Left .......... = Bone</td></tr><tr><td valign="top" width="167"></td><td colspan="2" valign="top" width="63"></td><td colspan="2" valign="top" width="49"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td valign="top" width="42"></td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167">Additional testing (if indicated)</td><td colspan="2" valign="top" width="63">Not</td><td colspan="2" valign="top" width="49">Normal</td><td valign="top" width="58">Abnormal</td><td valign="top" width="18"></td><td width="42">dB/HL</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167"></td><td colspan="2" valign="top" width="63">performed</td><td colspan="2" valign="top" width="49"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td width="42">–10</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167">(414) Speech audiometry</td><td colspan="2" valign="top" width="63"></td><td colspan="2" valign="top" width="49"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td width="42"> 0</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167">(415) Posterior rhinoscopy</td><td colspan="2" valign="top" width="63"></td><td colspan="2" valign="top" width="49"></td><td valign="top" width="58"></td><td valign="top" width="18"></td><td width="42"> 10</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td rowspan="2" valign="top" width="167">(416) EOG; spontaneous and positional nystagnus</td><td colspan="5" rowspan="2" valign="top" width="170"></td><td valign="top" width="18"></td><td width="42"> 20</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="18"></td><td width="42"> 30</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167">(417) Differential caloric test or</td><td colspan="5" rowspan="2" valign="top" width="170"></td><td valign="top" width="18"></td><td width="42"> 40</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167"> vestibular autorotation test</td><td valign="top" width="18"></td><td width="42"> 50</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167">(418) Mirror or fibre laryngoscopy</td><td colspan="5" rowspan="2" valign="top" width="170"></td><td valign="top" width="18"></td><td width="42"> 60</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167"></td><td valign="top" width="18"></td><td width="42"> 70</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="167"></td><td colspan="2" valign="top" width="63"></td><td colspan="3" width="107"></td><td valign="top" width="18"></td><td width="42"> 80</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td colspan="6" valign="top" width="337">(421) Otorhinolaryngology remarks and recommendation:</td><td valign="top" width="18"></td><td width="42">90</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td colspan="6" rowspan="4" valign="top" width="337"></td><td valign="top" width="18"></td><td width="42">100</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="18"></td><td width="42">110</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="18"></td><td width="42">120</td><td colspan="2" valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td colspan="2" valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td><td valign="top" width="26"></td></tr><tr><td valign="top" width="18"></td><td colspan="12" valign="top" width="249">Hz 250 500 1000 2000 3000 4000 6000 8000</td></tr><tr height="0"></tr></table>

<table border="0" cellpadding="0" cellspacing="0" width="604"><tr><td colspan="3" valign="top" width="604">(422) Examiner’s declaration:</td></tr><tr><td colspan="3" valign="top" width="604">I hereby certify that I/my AME group have personally examined the applicant named on this medical examination report and that this report with any attachment embodies my findings completely and correctly.</td></tr><tr><td valign="top" width="192">(423) Place and date:</td><td valign="top" width="232">ORL examiner’s name and address: (block capitals)</td><td valign="top" width="180">AME or specialist stamp with No: </td></tr><tr><td valign="top" width="192"></td><td valign="top" width="232"></td><td valign="top" width="180"></td></tr><tr><td valign="top" width="192">AME signature:</td><td valign="top" width="232"></td><td valign="top" width="180"></td></tr><tr><td valign="top" width="192"></td><td valign="top" width="232">E-mail:Telephone No.:Telefax No.:</td><td valign="top" width="180"></td></tr></table>

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.

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 ........’.

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

ED
Decision 2012/006/R

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**

<table border="1" cellpadding="0" cellspacing="0" width="603">
<tr>
<td valign="top" width="222">
(1) State applied
 to:
</td>
<td colspan="3" valign="top" width="382">
(2) Medical
 certificate applied for: class 1               class 2    
</td>
</tr>
<tr>
<td valign="top" width="222">
(3) Surname:
</td>
<td colspan="2" valign="top" width="222">
(4) Previous
 surname(s):
</td>
<td valign="top" width="160">
(12) Application:  Initial     

      Revalidation/Renewal  
</td>
</tr>
<tr>
<td valign="top" width="222">
(5) Forename(s):
</td>
<td valign="top" width="152">
(6) Date of
 birth:
</td>
<td valign="top" width="70">
(7) Sex: Male      
Female  
</td>
<td valign="top" width="160">
(13) Reference
 number:
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="603">
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</v:rect>(301) Consent to release of medical information: I hereby authorise
 the release of all information contained in this report and any or all
 attachments to the AME and, where necessary, to the medical assessor of the licensing
 authority, recognising that these documents or electronically stored data,
 are to be used for completion of a medical assessment and will become and
 remain the property of the licensing authority, providing that I or my
 physician may have access to them according to national law. Medical
 confidentiality will be respected at all times.
----------------------------------------        ---------------------------------------------------------------        ---------------------------------------------------------------
                   Date                                                     Signature of applicant                                                         Signature of AME
</td>
</tr>
<tr height="0">
</tr>
</table>

<table border="1" cellpadding="0" cellspacing="0" width="603">
<tr>
<td valign="top" width="158">
(302) Examination
 category:
</td>
<td valign="top" width="445">
(303)
 Ophthalmological history:
</td>
</tr>
<tr>
<td valign="top" width="158">
          Initial                        
</td>
<td valign="top" width="445">
</td>
</tr>
<tr>
<td valign="top" width="158">
          Revalidation             
</td>
<td valign="top" width="445">
</td>
</tr>
<tr>
<td valign="top" width="158">
          Renewal                   
</td>
<td valign="top" width="445">
</td>
</tr>
<tr>
<td valign="top" width="158">
          Special referral        
</td>
<td valign="top" width="445">
</td>
</tr>
</table>

**Clinical
examination**                                                                                **Visual acuity**

<table border="1" cellpadding="0" cellspacing="0" width="604">
<tr>
<td colspan="4" valign="top" width="170">
Check each item
</td>
<td width="51">
Normal
</td>
<td width="59">
Abnormal
</td>
<td valign="top" width="20">
</td>
<td colspan="6" valign="top" width="185">
(314) Distant vision at 5m/6m
                    Uncorrected
</td>
<td colspan="2" valign="top" width="64">
Spectacles
</td>
<td colspan="2" valign="top" width="56">
Contact lenses
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
(304) Eyes,
 external &amp; eyelids
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Right eye
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
(305) Eyes,
 Exterior
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Left eye
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
        (slit lamp, ophth.)
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Both eyes
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
(306) Eye
 position and movements
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td colspan="6" valign="top" width="185">
(315) Intermediate vision at 1m
              Uncorrected
</td>
<td colspan="2" valign="top" width="64">
Spectacles
</td>
<td colspan="2" valign="top" width="56">
Contact lenses
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
(307) Visual
 fields (confrontation)
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Right eye
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
(308) Pupillary
 reflexes
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Left eye
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
(309) Fundi
 (Ophthalmoscopy)
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Both eyes
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td valign="top" width="121">
(310) Convergence
</td>
<td colspan="3" valign="top" width="50">
cm
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td colspan="6" valign="top" width="185">
(316) Near vision at 30-50cm
                    Uncorrected
</td>
<td colspan="2" valign="top" width="64">
Spectacles
</td>
<td colspan="2" valign="top" width="56">
Contact lenses
</td>
</tr>
<tr>
<td valign="top" width="121">
(311)
 Accommodation
</td>
<td colspan="3" valign="top" width="50">
D
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Right eye
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="170">
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Left eye
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
(312) Ocular muscle balance (in prisme
 dioptres) 
</td>
<td valign="top" width="20">
</td>
<td valign="top" width="58">
Both eyes
</td>
<td colspan="2" valign="top" width="57">
</td>
<td colspan="3" valign="top" width="70">
Corrected to
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="137">
Distant at 5m/6m
</td>
<td colspan="4" valign="top" width="143">
Near at 30-50 cm
</td>
<td valign="top" width="20">
</td>
<td colspan="2" valign="top" width="86">
</td>
<td colspan="4" valign="top" width="99">
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="137">
Ortho
</td>
<td colspan="4" valign="top" width="143">
Ortho
</td>
<td valign="top" width="20">
</td>
<td colspan="2" valign="top" width="86">
(317) Refraction
</td>
<td colspan="2" width="49">
Sph
</td>
<td colspan="2" width="50">
Cylinder
</td>
<td width="58">
Axis
</td>
<td colspan="3" width="62">
Near
 (add)
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="137">
Eso
</td>
<td colspan="4" valign="top" width="143">
Eso
</td>
<td valign="top" width="20">
</td>
<td colspan="2" valign="top" width="86">
Right eye
</td>
<td colspan="4" valign="top" width="99">
</td>
<td valign="top" width="58">
</td>
<td colspan="3" valign="top" width="62">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="137">
Exo
</td>
<td colspan="4" valign="top" width="143">
Exo
</td>
<td valign="top" width="20">
</td>
<td colspan="2" valign="top" width="86">
Left eye
</td>
<td colspan="4" valign="top" width="99">
</td>
<td valign="top" width="58">
</td>
<td colspan="3" valign="top" width="62">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="137">
Hyper
</td>
<td colspan="4" valign="top" width="143">
Hyper
</td>
<td valign="top" width="20">
</td>
<td colspan="10" valign="top" width="304">
Actual refraction
 examined   Spectacles prescription based 
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="137">
Cyclo
</td>
<td colspan="4" valign="top" width="143">
Cyclo
</td>
<td valign="top" width="20">
</td>
<td colspan="2" valign="top" width="86">
</td>
<td colspan="4" valign="top" width="99">
</td>
<td colspan="3" valign="top" width="64">
</td>
<td valign="top" width="55">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
Tropia   
    Yes       No                   Phoria         Yes        No 
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
(318) Spectacles  
</td>
<td colspan="5" valign="top" width="160">
(319) Contact lenses
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
Fusional reserve
 testing  Not performed    Normal  
 Abnormal
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
Yes        No 
  
</td>
<td colspan="5" valign="top" width="160">
Yes        No 
  
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
(313) Colour perception
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
Type:
</td>
<td colspan="5" valign="top" width="160">
Type:
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="142">
Pseudo-Isochromatic
 plates
</td>
<td colspan="3" valign="top" width="138">
Type: Ishihara
 (24 plates)
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
</td>
<td colspan="5" valign="top" width="160">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="142">
No of plates: 
</td>
<td colspan="2" valign="top" width="79">
No of errors:
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="20">
</td>
<td colspan="10" valign="top" width="304">
(320) Intra-ocular pressure
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
Advanced colour
 perception testing indicated    
 Yes         No 
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
Right (mmHg)
</td>
<td colspan="5" valign="top" width="160">
Left (mmHg)
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
Method:
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
</td>
<td colspan="5" valign="top" width="160">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
Colour SAFE                Colour UNSAFE
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
Method
</td>
<td colspan="5" valign="top" width="160">
Normal        Abnormal  
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="280">
</td>
<td valign="top" width="20">
</td>
<td colspan="5" valign="top" width="145">
</td>
<td colspan="5" valign="top" width="160">
</td>
</tr>
<tr height="0">
</tr>
</table>

(321) **Ophthalmological remarks and
recommendation:**

(322) **Examiner’s declaration:**

<table border="1" cellpadding="0" cellspacing="0" width="603">
<tr>
<td colspan="3" valign="top" width="603">
I hereby certify
 that I/my AME group have personally examined the applicant named on this
 medical examination report and that this report with any attachment embodies
 my findings completely and correctly.
</td>
</tr>
<tr>
<td valign="top" width="192">
(323) Place and
 date:
</td>
<td valign="top" width="245">
Ophth examiner’s
 name and address: (block capitals)
</td>
<td valign="top" width="166">
AME or specialist
 stamp with No.:
</td>
</tr>
<tr>
<td valign="top" width="192">
AME signature:
</td>
<td valign="top" width="245">
E-mail:
Telephone No.:
Telefax No.:
</td>
<td valign="top" width="166">
</td>
</tr>
</table>

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**

<table border="1" cellpadding="0" cellspacing="0" width="603">
<tr>
<td valign="top" width="217">
(1) State applied
 to:
</td>
<td colspan="3" valign="top" width="386">
(2) Medical
 certificate applied for: class 1               class 2    
</td>
</tr>
<tr>
<td valign="top" width="217">
(3) Surname:
</td>
<td colspan="2" valign="top" width="234">
(4) Previous
 surname(s):
</td>
<td valign="top" width="152">
(12) Application:  Initial     
     Revalidation/Renewal   
</td>
</tr>
<tr>
<td valign="top" width="217">
(5) Forename(s):
</td>
<td valign="top" width="165">
(6) Date of
 birth:
</td>
<td valign="top" width="69">
(7) Sex: Male      
Female  
</td>
<td valign="top" width="152">
(13) Reference
 number:
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="603">
(401) Consent to release of medical
 information: I hereby authorise the release of all information contained
 in this report and any or all attachments to the AME and, where necessary,
 to the medical assessor of the licensing authority, recognising that these
 documents, or any electronically stored data, are to be used for completion
 of a medical assessment and will become and remain the property of the
 licensing authority, providing that I or my physician may have access to
 them according to national law. Medical confidentiality will be respected at
 all times.
---------------------------------------         --------------------------------------------------------------          --------------------------------------------------------------
                   Date                                                     Signature of applicant                                                       Signature of AME
</td>
</tr>
<tr height="0">
</tr>
</table>

<table border="1" cellpadding="0" cellspacing="0" width="603">
<tr>
<td valign="top" width="158">
(402) Examination
 category:
</td>
<td valign="top" width="445">
(403)
 Otorhinolaryngological history:
</td>
</tr>
<tr>
<td valign="top" width="158">
</td>
<td valign="top" width="445">
</td>
</tr>
<tr>
<td valign="top" width="158">
          Initial                        
</td>
<td valign="top" width="445">
</td>
</tr>
<tr>
<td valign="top" width="158">
          Special referral         
</td>
<td valign="top" width="445">
</td>
</tr>
<tr>
<td valign="top" width="158">
</td>
<td valign="top" width="445">
</td>
</tr>
</table>

**Clinical examination**

<table border="1" cellpadding="0" cellspacing="0" width="604">
<tr>
<td colspan="2" valign="top" width="221">
Check each item
</td>
<td colspan="3" valign="top" width="58">
Normal
</td>
<td valign="top" width="58">
Abnormal
</td>
<td valign="top" width="18">

</td>
<td colspan="12" valign="top" width="249">
(419) Pure tone audiometry
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(404) Head, face,
 neck, scalp
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="12" valign="top" width="249">
dB HL (hearing
 level)
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(405) Buccal
 cavity, teeth
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" valign="top" width="53">
Hz
</td>
<td colspan="6" valign="top" width="104">
Right ear
</td>
<td colspan="4" valign="top" width="92">
Left ear
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(406) Pharynx
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
250
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(407) Nasal
 passages and naso-pharynnx
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
500
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
        (incl. anterior rhinoscopy)
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
1000
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(408) Vestibular
 system incl. Romberg test
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
2000
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(409) Speech
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
3000
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(410) Sinuses
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
4000
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(411) Ext
 acoustic meati, tympanic membranes
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
6000
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(412) Pneumatic
 otoscopy
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" width="53">
8000
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
(413) Impedance
 tympanometry including
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="2" valign="top" width="53">
</td>
<td colspan="6" valign="top" width="104">
</td>
<td colspan="4" valign="top" width="92">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">
         Valsalva menoeuvre (initial only)
</td>
<td colspan="3" valign="top" width="58">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td colspan="12" valign="top" width="249">
(420) Audiogram
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="221">

</td>
<td colspan="2" valign="top" width="19">
</td>
<td valign="top" width="39">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="31">
</td>
<td colspan="8" valign="top" width="176">
o = Right              – – –  = Air 
 x = Left               .......... = Bone
</td>
</tr>
<tr>
<td valign="top" width="167">

</td>
<td colspan="2" valign="top" width="63">
</td>
<td colspan="2" valign="top" width="49">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td valign="top" width="42">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
Additional testing (if indicated)
</td>
<td colspan="2" valign="top" width="63">
Not
</td>
<td colspan="2" valign="top" width="49">
Normal
</td>
<td valign="top" width="58">
Abnormal
</td>
<td valign="top" width="18">
</td>
<td width="42">
dB/HL
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
</td>
<td colspan="2" valign="top" width="63">
performed
</td>
<td colspan="2" valign="top" width="49">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td width="42">
–10
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
(414) Speech
 audiometry
</td>
<td colspan="2" valign="top" width="63">
</td>
<td colspan="2" valign="top" width="49">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td width="42">
    0
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
(415) Posterior
 rhinoscopy
</td>
<td colspan="2" valign="top" width="63">
</td>
<td colspan="2" valign="top" width="49">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="18">
</td>
<td width="42">
  10
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td rowspan="2" valign="top" width="167">
(416) EOG;
 spontaneous and
          positional nystagnus
</td>
<td colspan="5" rowspan="2" valign="top" width="170">
</td>
<td valign="top" width="18">
</td>
<td width="42">
  20
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="18">
</td>
<td width="42">
  30
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
(417)
 Differential caloric test or
</td>
<td colspan="5" rowspan="2" valign="top" width="170">
</td>
<td valign="top" width="18">
</td>
<td width="42">
  40
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
         vestibular autorotation test
</td>
<td valign="top" width="18">
</td>
<td width="42">
  50
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
(418) Mirror or
 fibre laryngoscopy
</td>
<td colspan="5" rowspan="2" valign="top" width="170">
</td>
<td valign="top" width="18">
</td>
<td width="42">
  60
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
</td>
<td valign="top" width="18">
</td>
<td width="42">
  70
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="167">
</td>
<td colspan="2" valign="top" width="63">
</td>
<td colspan="3" width="107">
</td>
<td valign="top" width="18">
</td>
<td width="42">
  80
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="337">
(421) Otorhinolaryngology remarks and
 recommendation:
</td>
<td valign="top" width="18">
</td>
<td width="42">
90
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td colspan="6" rowspan="4" valign="top" width="337">
</td>
<td valign="top" width="18">
</td>
<td width="42">
100
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="18">
</td>
<td width="42">
110
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="18">
</td>
<td width="42">
120
</td>
<td colspan="2" valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td colspan="2" valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="26">
</td>
</tr>
<tr>
<td valign="top" width="18">
</td>
<td colspan="12" valign="top" width="249">
Hz     250    
 500   1000   2000  
 3000  4000  6000 
 8000
</td>
</tr>
<tr height="0">
</tr>
</table>

<table border="0" cellpadding="0" cellspacing="0" width="604">
<tr>
<td colspan="3" valign="top" width="604">
(422) Examiner’s declaration:
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="604">
I hereby certify
 that I/my AME group have personally examined the applicant named on this
 medical examination report and that this report with any attachment embodies
 my findings completely and correctly.
</td>
</tr>
<tr>
<td valign="top" width="192">
(423) Place and
 date:
</td>
<td valign="top" width="232">
ORL examiner’s
 name and address: (block capitals)
</td>
<td valign="top" width="180">
AME or specialist
 stamp with No: 
</td>
</tr>
<tr>
<td valign="top" width="192">
</td>
<td valign="top" width="232">
</td>
<td valign="top" width="180">
</td>
</tr>
<tr>
<td valign="top" width="192">
AME signature:
</td>
<td valign="top" width="232">
</td>
<td valign="top" width="180">
</td>
</tr>
<tr>
<td valign="top" width="192">
</td>
<td valign="top" width="232">
E-mail:
Telephone No.:
Telefax No.:
</td>
<td valign="top" width="180">
</td>
</tr>
</table>

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 ........’.