Request for Aeromedical Consultation

Please complete all fields to the best of your ability.

Personal Information

FAA Information

Date of Last FAA Airman Application

No Prior Application

Date Of Birth

Type of Airman Certificate(s) You Hold:

None

Airline Transport

Commercial

Atc Specialist

Flight Engineer

Flight Navigator

Flight Instructor

Private

Student

Recreational

Class of Medical Held or Sought:

1st Class

2nd Class

3rd Class

FAA Medical History:

I currently hold an FAA medical certificate

I have previously held an FAA medical certificate (no longer current)

I have never held an FAA medical certificate

Medical History

Has Your FAA Airman Medical Certificate Ever Been Denied, Suspended, or Revoked?

Yes

Do You Currently Use Any Medication (Prescription or Nonprescription)?

Yes

Have you ever in your life been diagnosed with, had, or do you presently have any of the following? (Check all that apply)

Frequent or severe headaches

Heart or vascular trouble

Mental disorders of any sort; depression, anxiety, ADD, ADHD, etc.

Dizziness or fainting spell

Sleep Apnea

Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years.

Unconscious for any reason

Stomach, liver, or intestinal trouble

Alcohol dependence or abuse

Eye or vision trouble except glasses

Kidney stone or blood in urine

Suicide Attempt

Hay fever or allergies

Diabetes

Motion sickness requiring medication

Asthma or lung disease

Neurological disorders: epilepsy, seizures, stroke, paralysis, etc.

Military Medical Discharge

Medical rejection by military service

Rejection for life or health insurance

Admission to hospital

Other illness, disability, or surgery

Medical disability benefits

Arrest, Conviction, and/or Administrative Action History

History of arrest(s) and/or conviction(s) for driving under the influence of alcohol or drugs, or administrative action(s) which resulted in the denial, suspension, cancellation, or revocation of driving privileges.

History of other (nontraffic) conviction(s) (misdemeanors or felonies).

Visit to Health Professional Within the Last 3 Years

FAA Deferral Document (Optional)

If you have received an FAA deferral letter, you may upload it here. Accepted formats: PDF, JPG, PNG.

Click to select file

Digital Signature

By submitting this form, you attest that the information provided is true and correct to the best of your knowledge.

Date