CHAPTER 2

Guide for Aviation Medical Examiners

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APPLICATION FOR MEDICAL CERTIFICATION

ITEMS 1- 20 of FAA Form 8500-8

This section contains guidance for items on the Medical History and General Information page

of FAA Form 8500-8, Application for Airman Medical Certificate or Airman Medical and

Student Pilot Certificate.

I. AME Guidance for Positive Identification of Airmen and Application Distribution

Procedures

All applicants must be asked to show proof of age and identity. On occasion,

individuals have attempted to be examined under a false name. If the applicant is

unknown to the Examiner, the Examiner should request evidence of positive

identification. A Government issued photo identification (e.g., driver’s license,

identification card issued by a driver’s license authority, military identification, or

passport) provides age and identity and is preferred. Applicants may use other

government-issued identification for age (e.g., certified copy of a birth certificate);

however, the Examiner must request separate photo identification for identity

(such as a work badge). Verify that the address provided is the same as that

given under Item 5, page 24. Record the type of identification(s) provided and

identifying number(s) under Item 61, page 154. Make a copy of the identification

and keep it on file for 3 years with the AME work copy.

An applicant who does not have government-issued photo identification may use non-

photo government-issued identification (e.g. pilot certificate, birth certificate, voter

registration card) in conjunction with a photo identification (e.g. work identification card,

student identification card).

If an airman fails to provide identification, the Examiner must report this immediately to the

AMCD, or the appropriate RFS for guidance.

II. Distribution of the FAA Form 8500-8 to the Applicant.

Both the yellow and white certificates and their instructions must be removed before the

application is given to the applicant. The Information for Applicant and Instructions for

Completion of the Application pages must also be given to the applicant.

On the general information and medical history page of the application, the applicant is

to fill in Items 1-20 in his or her handwriting using a ballpoint pen, exerting sufficient

pressure for all copies, to make legible imprints upon the Examiner's and airman’s

copies of the form.

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III. After the Applicant Completes the Medical History Page of the

FAA Form 8500-8:

The Examiner must ensure completeness and review all items 1 through 20. A medical

certificate must never be issued to an applicant who refuses to answer Item 13, page

26; Items 16 and 17, page 27; Item 18, page 29; or Item 19, page 34; or to an applicant

who refuses to sign the form (Item 20, front side of the examination form). The date for

Item 16 may be estimated if the applicant does not recall the actual date of the last

examination. However, for the sake of electronic transmission, it must be placed in the

mm/dd/yyyy format. (See Item 16, page 27).

Verify that the name on the applicant's identification media matches the name on the

FAA Form 8500-8. If it does not, question the applicant for an explanation. If the

explanation is not reasonable (legal name change, subsequent marriage, etc.), do not

continue the medical examination or issue a medical certificate. Contact your RFS for

guidance.

The applicant's Social Security Number (SSN) is not mandatory. Failure to provide is

not grounds for refusal to issue a medical certificate. (See Item 4, page 24). All other

items on the form must be completed.

Applicants must provide their home address on the FAA Form 8500-8. Applicants may use a

private mailing address (e.g., a P.O. Box number or a mail drop) if that is their preferred

mailing address; however, under Item 18 (in the "Explanations" box) of the FAA Form 8500-8,

they must provide their home address.

The applicant must personally enter all data and make all corrections on the application

form. The applicant should initial all corrections. The application constitutes a legal

document and must be completed in the applicant's handwriting. If for any reason

someone other than the applicant enters information in Items 1-20, the person should

initial beside that item (including any check marks), and the Examiner should add a note

explaining in Item 60, page 153, the person's inability to enter the data.

Strict compliance with this procedure is essential in case it becomes necessary for the

FAA to take legal action for falsification of the application.

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ITEMS 1-2. APPLICATION FOR; CLASS OF MEDICAL CERTIFICATE APPLIED

FOR

1. Application For:

2. Class of Medical

Certificate Applied For:

Airman Medical

Certificate

Airman Medical and

Student Pilot Certificate

2nd

3rd

The applicant indicates whether the application is for an Airman Medical Certificate

(white) or an Airman Medical and Student Pilot Certificate (yellow), and the class of

medical certificate desired.

The class of medical certificate sought by the applicant is needed so that the

appropriate medical standards may be applied. The class of certificate issued must

correspond with that for which the applicant has applied.

The applicant may ask for a medical certificate of a higher class than needed for the

type of flying or duties currently performed. For example, a student pilot may ask for a

first-class medical certificate to see if he or she qualifies medically before entry into an

aviation career.

The Examiner applies the standards appropriate to the class

sought, not to the airman's

duties - either performed or anticipated. The Examiner should never issue more than

one certificate based on the same examination.

ITEMS 3-10. IDENTIFICATION

3. Last Name First Name Middle Name

4. Social Security Number - -

5. Address Telephone Number ( )

Number/Street

City State/Country Zip Code

6. Date of Birth 7. Color of Hair 8. Color of Eyes 9. Sex

MM / DD / YYYY

Citizenship

10. Type of Airman Certificate(s) you hold

None

ATC Specialist

Flight Instructor

Recreational

Airline Transport

Flight Engineer

Private

Other

Commercial

Fight Navigator

Student

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The following information is required for identification of the individual who is applying

for medical certification:

Item 3. Last Name; First Name; Middle Name

The applicant's last, first, and middle name (or initial if appropriate) must be printed. All

applicants without a middle name should enter "NMN" or "NONE". Nicknames and

abbreviated names must not be used. NOTE: If the applicant's name changed for any

reason, the current name is listed on the application and any former name(s) in the

EXPLANATIONS box of Item 18 on the application.

Item 4. Social Security Number (SSN)

Although applicants are asked to complete all questions on the application, the FAA

Form 8500-8, they are not legally required to complete Item 4. The FAA requests the

SSN for identification purposes and record control. Its use as a unique identifier may

eliminate a mistake in identification.

Item 5. Address and Telephone Number

The applicant must print a permanent mailing address, including country, and the

zip code (full nine digits if known). The person must also provide a current daytime

area code and telephone number.

Item 6. Date of Birth

The applicant must enter the numbers for the month, day, and year of birth in order

(e.g., 04/29/2000 for April 29, 2000). Name, date of birth, and SSN are the basic

identifiers of airmen. When an Examiner wishes to communicate with the FAA

concerning an applicant, the Examiner must give the applicant's full name, date of birth,

and SSN if at all possible. The applicant should indicate citizenship; e.g., U.S.A.

If the applicant wishes to be issued an Airman Medical and Student Pilot Certificate

(FAA Form 8420-2), the Examiner should check the date of birth to ensure that the

applicant is at least 16 years old. Unless the applicant is at least 16 years old, a

combined Airman Medical and Student Pilot Certificate may not be issued, even if the

applicant will become 16 years old before the certificate expires (except as noted

below).

The FAA will not confirm a certificate issued by an Examiner to a person who is less

than 16 years old. The applicant must be at least 16 years old at the time of

application to be eligible for a student pilot certificate for flight of powered aircraft. This

minimum age requirement applies only to the issuance of the yellow FAA Form 8420-2,

and never to the issuance of the white medical certificate (FAA Form 8500-9).

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If the applicant is not yet 16 years old and wishes to solo on or after his or her 16th

birthday, the Examiner should issue a white FAA Form 8500-9 (if the applicant is fully

qualified medically). On or after his or her 16th birthday, the applicant may obtain a

student pilot certificate for the flight from a FAA Flight Standards District Office (FSDO)

or designated Flight Examiner upon presentation of the FAA Form 8500-9 (white

medical certificate).

An alternative procedure for this situation is for the Examiner to issue the Airman

Medical and Student Pilot Certificate, FAA Form 8420-2 (yellow), with the following

statement in the limitations block of the student pilot certificate:

NOT VALID UNTIL (MONTH, DAY, AND YEAR OF 16TH BIRTHDAY)

This procedure should not be used if the applicant's 16th birthday will occur more than

30 days from the date of application.

Although nonmedical regulations allow an airman to solo a glider or balloon at age 14, a

medical certificate is not required for glider or balloon operations. These airmen are

required to certify to the FAA that they have no known physical defects that make them

unable to pilot a glider or balloon. This certification is made at the FAA FSDO’s.

There is a maximum age requirement for certain air carrier pilots. Because this is not a

medical requirement but an operational one, the Examiner may issue medical

certificates without regard to age to any applicant who meets the medical standards.

Item 7. Color of Hair

Color of hair should be entered as "brown," "black," "blonde," "gray," or "red." Lack of

hair should be entered as

"bald." No abbreviations or other colors should be used. This

information is for identification only.

Item 8. Color of Eyes

Color of eyes should be entered as "brown," "black," "blue," "hazel," "gray," or "green."

No abbreviations or other colors should be used. This information is for identification

only.

Item 9. Sex

The applicant should enter either male or female.

Item 10. Type of Airman Certificate(s) You Hold

Applicant checks appropriate block(s).

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ITEMS 11-12. OCCUPATION; EMPLOYER

11. Occupation 12. Employer

Occupational data are principally used for statistical purposes. This information, along

with information obtained from Items 10, page 25, Items 14 and 15, page 27, may be

important in determining whether a SODA may be issued, if applicable.

11. Occupation

This should reflect the applicant's major employment. "Pilot" should only be reported

when the applicant earns a livelihood from flying.

12. Employer

The employer's name should be entered by the applicant.

ITEM 13. HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED,

SUSPENDED, OR REVOKED?

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

Yes No If yes, give date _____________________

MM / DD / YYYY

The applicant shall check "yes" or "no." If "yes" is checked, the applicant should enter

the date of action and should report details in the EXPLANATIONS box of Item 18,

page 29.

The Examiner may not issue a medical certificate to an applicant who has checked

"yes." The only exceptions to this prohibition are:

• The applicant presents written evidence from the FAA that he or she was

subsequently medically certificated and that an Examiner is authorized to issue a

renewal medical certificate to the person if medically qualified; or

• The Examiner obtains oral or written authorization to issue a medical certificate

from an FAA medical office

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ITEMS 14-15. TOTAL PILOT TIME

Total Pilot Time (Civilian Only)

14. To Date 15. Past 6 months

14. Total Pilot Time to Date

The applicant should indicate the total number of civilian flight hours and whether those

hours are logged (LOG) or estimated (EST).

15. Total Pilot Time Past 6 Months

The applicant should provide the number of civilian flight hours in the 6-month period

immediately preceding the date of this application. The applicant should indicate

whether those hours are logged (LOG) or estimated (EST).

ITEM 16. DATE OF LAST FAA MEDICAL APPLICATION

Date of Last FAA Medical Application

MM/DD/YYY No Prior Application

If a prior application was made, the applicant should indicate the date of the last

application, even if it is only an estimate of the year. This item should be completed

even if the application was made many years ago or the previous application

did not

result in the issuance of a medical certificate. If no prior application was made, the

applicant should check the appropriate block in Item 16.

ITEM 17.a. DO YOU CURRENTLY USE ANY MEDICATION (PRESCRIPTION OR

NONPRESCRIPTION)?

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

Yes

(If yes, list below medication(s) used and check appropriate box).

Previously Reported

Yes

(If more space is required, see 17.a. on the instruction sheet).

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If the applicant checks yes, give name of medication(s) and indicate if the medication

was listed in a previous FAA medical examination.

This includes both prescription and nonprescription medication. (Additional guidelines

for the certification of airmen who use medication may be found in throughout the

Guide).

For example, any airman who is undergoing continuous treatment with anticoagulants,

antiviral agents, anxiolytics, barbiturates, chemotherapeutic agents, experimental

hypoglycemic, investigational, mood-ameliorating, motion sickness, narcotic, sedating

antihistaminic, sedative, steroid drugs, or tranquilizers must be deferred certification

unless the treatment has previously been cleared by FAA medical authority. In such an

instance, the applicant should provide the Examiner with a copy of any FAA

correspondence that supports the clearance.

During periods in which the foregoing medications are being used for treatment of acute

illnesses, the airman is under obligation to refrain from exercising the privileges of

his/her airman medical certificate unless cleared by the FAA.

Further information concerning an applicant's use of medication may be found

under the items pertaining to specific medical condition(s) for which the medication is

used, or you may contact your RFS.

ITEM 17.b. DO YOU EVER USE NEAR VISION CONTACT LENS(ES) WHILE

FLYING?

17.b. Do You Ever Use Near Vision Contact Lens(es) While Flying?

Yes

The applicant should indicate whether near vision contact lens(es) is/are used while

flying. If the applicant answers "yes," the Examiner should counsel the applicant that

the use of contact lens(es) (bifocal or unifocal) specifically for the correction of near

vision is/are inappropriate. The Examiner must note in Item 60, page 153 that this

counseling has been given.

If the applicant checks "yes" and no further comment is noted on FAA Form 8500-8 by

either the applicant or the Examiner, a letter will automatically be sent to the applicant

informing him or her that the use of contact lens(es) specifically to correct near vision

is/are inappropriate for flying.

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ITEM 18. MEDICAL HISTORY

18. Medical History - HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING? Answer “yes” or “no”

for every condition listed below. In the EXPLANATIONS box below, you may note ‘PREVIOUSLY REPORTED, NO CHANGE” only if the explanation of the condition

was reported on a previous application for an airman medical certificate and there has been no change in your condition.

See Instructions Page

Yes No

Frequent or severe headaches

Dizziness or fainting spell

Unconsciousness for any reason

Eye or vision trouble except glasses

Hay fever or allergy

Asthma or lung disease

Condition

Yes No Condition

Heart or vascular trouble

High or low blood pressure

Stomach, liver, or intestinal

trouble

Kidney stone or blood in urine

Diabetes

Yes No Condition

Mental disorders of any sort;

depression, anxiety, etc.

Substance dependence or failed a drug

test ever; or substance abuse or use

of illegal substance in the last 2 years

Alcohol dependence or abuse

Suicide attempt

Motion sickness requiring medication

Military medical discharge

Medical rejection by military service

Rejection for life or health insurance

Admission to hospital

Other illness, disability, or surgery

Yes No Condition

Conviction and/or Administrative Action History - See Instructions Page

Yes No

History of (1) any

conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence

of alcohol or a drug; or (2) history of any conviction(s) or administrative action(s) involving an offense(s) which

resulted in the denial, suspension, cancellation, or revocation of driving privileges or which resulted in attendance

at an educational or a rehabilitation program.

Yes No

History of nontraffic

conviction(s)(misdemeanors

or felonies).

EXPLANATIONS: See Instructions Page

Neurological disorders; epilepsy,

seizures, stroke, paralysis,. etc.

For FAA Use

Review Action Codes

Each item under this heading must be checked either "yes" or "no." For all items

checked "yes," a description and approximate date of every condition the applicant has

ever been diagnosed with, had, or presently has, must be given in the EXPLANATIONS

box. If information has been reported on a previous application for airman medical

certification and there has been no change in the condition, the applicant may note

"PREVIOUSLY REPORTED, NO CHANGE" in the EXPLANATIONS box, but the

applicant must still check "yes" to the condition.

Of particular importance are conditions that have developed since the last FAA medical

examination. If more space is needed, a plain sheet of paper bearing the applicant's full

printed name, date of birth, signature, and the date should be used.

The Examiner must take the time to review the applicant's responses on FAA

Form 8500-8 before starting the applicant's medical examination.

The Examiner should ensure that the applicant has checked all of the boxes in Item 18

as either "yes" or "no." The Examiner should use information obtained from this review

in asking the applicant pertinent questions during the course of the examination.

Certain aspects of the individual's history may need to be elaborated upon. The

Examiner should provide in Item 60, page 153 an explanation of the nature of items

checked "yes" in Items 18.a. through 18.x. An additional sheet may be added if

necessary.

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Supplementary reports from the applicant's physician(s) should be obtained and

forwarded to the AMCD, when necessary, to clarify the significance of an item of history.

The responsibility for providing such supplementary reports rests with the applicant. A

discussion with the Examiner's RFS may clarify and expedite the certification process at

that time.

Affirmative answers alone in Item 18 do not constitute a basis for denial of a medical

certificate. A decision concerning issuance or denial should be made by applying the

medical standards pertinent to the conditions uncovered by the history.

Experience has shown that, when asked direct questions by a physician, applicants are

likely to be candid and willing to discuss medical problems.

The Examiner should attempt to establish rapport with the applicant and to develop a

complete medical history. Further, the Examiner should be familiar with the FAA

certification policies and procedures in order to provide the applicant with sound advice.

18.a. Frequent or severe headaches. The applicant should report frequency, duration,

characteristics, severity of symptoms, neurologic manifestations, and whether they have

been incapacitating, treatment and side effects, if any. (See Item 46, page 103).

18.b. Dizziness or fainting spells. The applicant should describe characteristics of the

episode; e.g., spinning or lightheadedness, frequency, factors leading up to and

surrounding the episode, associated neurologic symptoms; e.g., headache, nausea,

LOC, or paresthesias. Include diagnostic workup and treatment if any.

(See Items 25-30, page 39; and

Item 46, page 103).

18.c. Unconsciousness for any reason. The applicant should describe the event(s) to

determine the primary organ system responsible for the episode, witness statements,

initial treatment, and evidence of recurrence or prior episode. Although the regulation

states, “an unexplained disturbance of consciousness is disqualifying,” it does not mean

to imply that the applicant can be certificated if the etiology is identified, because the

etiology may also be disqualifying in and of itself. (See

Item 46, page 103).

18.d. Eye or vision trouble except glasses. The Examiner should personally explore

the applicant's history by asking questions, concerning any changes in vision, unusual

visual experiences (halos, scintillations, etc.), sensitivity to light, injuries, surgery, or

current use of medication. Does the applicant report inordinate difficulties with eye

fatigue or strain? Is there a history of serious eye disease such as glaucoma or other

disease commonly associated with secondary eye changes, such as diabetes?

For glaucoma or ocular hypertension, obtain a FAA Form 8500-14, Report of Eye

Evaluation for Glaucoma. For any other medical condition, obtain a FAA Form 8500-7,

Report of Eye Evaluation. Under all circumstances, please advise the examining eye

specialist to explain why the airman is unable to correct to Snellen visual acuity of

20/20. (Also see Items 31-34, page 46; Item 53, page 142; and

Item 54, page 144).

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18.e. Hay fever or allergy. The applicant should report frequency and duration of

symptoms, and whether they have been incapacitating by the condition. Mention

should also be made of treatment and side effects. The Examiner should inquire

whether the applicant has ever experienced any “ear block”, barotitis, or any other

symptoms that could interfere with aviation safety? Barosinusitis is of concern and

should also be ruled out. (See Item 26, page 42).

18.f. Asthma or lung disease. The applicant should provide frequency and severity of

asthma attacks, medications, and number of visits to the hospital and/or emergency

room. For other lung conditions, a detailed description of symptoms/diagnosis, surgical

intervention, and medications should be provided. (See Item 35, page 57).

18.g. Heart or vascular trouble. The applicant should describe the condition to include,

dates, symptoms, and treatment, and provide medical reports to assist in the

certification decision-making process. These reports should include: operative reports

of coronary intervention to include the original cardiac catheterization report, stress

tests, worksheets, and original tracings (or a legible copy). When stress tests are

provided, forward the reports, worksheets and original tracings (or a legible copy) to the

FAA. Part 67 provides that, for all classes of medical certificates, an established

medical history or clinical diagnosis of myocardial infarction, angina pectoris, cardiac

valve replacement, permanent cardiac pacemaker implantation, heart replacement, or

coronary heart disease that has required treatment or, if untreated, that has been

symptomatic or clinically significant, is cause for denial. (See Item 36, page 63).

18.h. High or low blood pressure. The applicant should provide history and treatment.

Issuance of a medical certificate to an applicant with high blood pressure may depend

on the current blood pressure levels and whether the applicant is taking anti-

hypertensive medication. The Examiner should also determine if the applicant has a

history of complications, adverse reactions to therapy, hospitalization, etc.

(Details are given in

Item 36, page 63, and Item 55, page 146).

18.i. Stomach, liver, or intestinal trouble. The applicant should provide history and

treatment, pertinent medical records, current status report, and medication. If a surgical

procedure was done, the applicant must provide operative and pathology reports.

(See

Item 38 page 77).

18.j. Kidney stone or blood in urine. The applicant should provide history and

treatment, pertinent medical records, current status report and medication. If a

procedure was done, the applicant must provide the report and pathology reports.

(See Item 41, page 85).

18.k. Diabetes. The applicant should describe the condition to include, symptoms and

treatment. Comment on the presence or absence of hyperglycemic and/or

hypoglycemic episodes. A medical history or clinical diagnosis of diabetes mellitus

requiring insulin or other hypoglycemic drugs for control are disqualifying. The Examiner

can help expedite the FAA review by assisting the applicant in gathering medical

records and submitting a current specialty report. (See

Item 48, page 123).

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18.l. Neurological disorders; epilepsy, seizures, stroke, paralysis, etc. The applicant

should provide history and treatment, pertinent medical records, current status report

and medication. The Examiner should obtain details about such a history and report the

results. An established diagnosis of epilepsy, a transient loss of control of nervous

system function(s), or a disturbance of consciousness is a basis for denial no matter

how remote the history. Like all other conditions of aeromedical concern, the history

surrounding the event is crucial. Certification is possible if a satisfactory explanation

can be established. (See Item 46, page 103).

18.m. Mental disorders of any sort; depression, anxiety, etc. An affirmative answer to

Item 18.m. requires investigation through supplemental history taking. Dispositions will

vary according to the details obtained. An applicant with an established history of a

personality disorder that is severe enough to have repeatedly manifested itself by overt

acts, a psychosis disorder, or a bipolar disorder must be denied or deferred by the

Examiner. (See

Item 46, page 103; and Item 47, page 115).

18.n. Substance dependence; or failed a drug test ever; or substance abuse or use of

illegal substance in the last 2 years. "Substance" includes alcohol and other drugs

(e.g., PCP, sedatives and hypnotics, anxiolytics, marijuana, cocaine, opioids,

amphetamines, hallucinogens, and other psychoactive drugs or chemicals). For a "yes"

answer to Item 18.n., the Examiner should obtain a detailed description of the history. A

history of substance dependence or abuse is disqualifying. The Examiner must defer

issuance of a certificate if there is doubt concerning an applicant's substance use.

(See

Item 47, page 115).

18.o. Alcohol dependence or abuse. See Item 18.n.

18.p. Suicide attempt. A history of suicidal attempts or suicidal gestures requires

further evaluation. The ultimate decision of whether an applicant with such a history is

eligible for medical certification rests with the FAA. The Examiner should take a

supplemental history as indicated, assist in the gathering of medical records related to

the incident(s), and, if the applicant agrees, assist in obtaining psychiatric and/or

psychological examinations. (See

Item 47, page 115).

18.q. Motion sickness requiring medication. A careful history concerning the nature of

the sickness, frequency and need for medication is indicated when the applicant

responds affirmatively to this item. Because motion sickness varies with the nature of

the stimulus, it is most helpful to know if the problem has occurred in flight or under

similar circumstances. (See Item 29, page 44).

18.r. Military medical discharge. If the person has received a military medical

discharge, the Examiner should take additional history and record it in Item 60. It is

helpful to know the circumstances surrounding the discharge, including dates, and

whether the individual is receiving disability compensation. If the applicant is receiving

veteran's disability benefits, the claim number and service number are helpful in

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obtaining copies of pertinent medical records. The fact that the applicant is receiving

disability benefits does not necessarily mean that the application should be denied.

18.s. Medical rejection by military service. The Examiner should inquire about the

place, cause, and date of rejection and enter the information in

Item 60, page 153. It is

of great assistance to the applicant and the FAA if the Examiner can help obtain copies

of military documents for attachment to the FAA Form 8500-8. If a delay of more than

14-calendar days is expected, the Examiner should transmit FAA Form 8500-8 to the

FAA with a note specifying what documents will be forwarded later under separate

cover.

Disposition will depend upon whether the medical condition still exists or whether a

history of such a condition requires denial or deferral under the FAA medical standards.

18.t. Rejection for life or health insurance. The Examiner should inquire regarding the

circumstances of rejection. The supplemental history should be recorded in

Item 60,

page 153. Disposition will depend upon whether the medical condition still exists or

whether a history of such a condition requires denial or deferral under the FAA medical

standards.

18.u. Admission to hospital. For each admission, the applicant should list the dates,

diagnoses, duration, treatment, name of the attending physician, and complete address

of the hospital or clinic. If previously reported, the applicant may enter "PREVIOUSLY

REPORTED, NO CHANGE." A history of hospitalization does not disqualify an

applicant, although the medical condition that resulted in hospitalization may.

18.v. Conviction and/or Administrative Action History. The events to be reported are

specifically identified in Item 18.v. of FAA Form 8500-8. If "yes" is checked, the

applicant must describe the conviction(s) and/or administrative action(s) in the

EXPLANATIONS box. The description must include:

• The alcohol or drug offense for which the applicant was convicted or the type of

administrative action involved (e.g., attendance at an educational or rehabilitation

program in lieu of conviction; license denial, suspension, cancellation, or revocation

for refusal to be tested; educational safe driving program for multiple speeding

convictions; etc.);

• The name of the state or other jurisdiction involved; and

• The date of the conviction and/or administrative action

If there have been no new convictions or administrative actions since the last

application, the applicant may enter "PREVIOUSLY REPORTED, NO CHANGE."

Convictions and/or administrative actions affecting driving privileges may raise

questions about the applicant's fitness for certification and may be cause for

disqualification. (See Items 18.n. and 47, page 115).

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A single driving while intoxicated (DWI) conviction or administrative action usually is not

cause for denial if there are no other instances or indications of substance dependence

or abuse. The Examiner should inquire regarding the applicant's alcohol use history,

the circumstances surrounding the incident, and document those findings in Item 60,

page 153. (See Item 47, page 115).

NOTE: The Examiner should advise the applicant that the reporting of alcohol or

drug offenses (i.e., motor vehicle violation) on the history part of the medical

application does not relieve the airman of responsibility to report each motor vehicle

action to the FAA within 60 days of the occurrence to the Security and Investigations

Division, AMC-700; P.O. Box 25810; Oklahoma City, OK 73125-0810.

18.w. History of nontraffic convictions. The applicant must report any other (nontraffic)

convictions (e.g., assault, battery, public intoxication, robbery, etc.). The applicant

must name the charge for which convicted and the date of the conviction(s), and copies

of court documents (if available). (See

Item 47, page 115).

18.x. Other illness, disability, or surgery. The applicant should describe the nature of

these illnesses in the EXPLANATIONS box. If additional records, tests, or specialty

reports are necessary in order to make a certification decision, the applicant should so

be advised. If the applicant does not wish to provide the information requested by the

Examiner, the Examiner should defer issuance.

If the applicant wishes to have the FAA review the application and decide what ancillary

documentation is needed, the Examiner should defer issuance of the medical certificate

and forward the completed FAA Form 8500-8 to the AMCD. If the Examiner proceeds

to obtain documentation, but all data will not be received with the 2 weeks,

FAA Form 8500-8 should be transmitted immediately to the AMCD with a note that

additional documents will be forwarded later under separate cover.

ITEM 19. VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS

19. Visits to Health Professional Within Last 3

Years

Yes

(Explain Below)

See Instructions Page

Date Name, Address, and Type of Health Professional Consulted Reason

The applicant should list all visits in the last 3 years to a physician, physician assistant,

nurse practitioner, psychologist, clinical social worker, or substance abuse specialist for

treatment, examination, or medical/mental evaluation. The applicant should list visits for

counseling only if related to a personal substance abuse or psychiatric condition.

LAST UPDATE: April 3, 2006

Guide for Aviation Medical Examiners

________________________________________________________________

The applicant should give the name, date, address, and type of health professional

consulted and briefly state the reason for the consultation. Multiple visits to one health

professional for the same condition may be aggregated on one line.

Routine dental, eye, and FAA periodic medical examinations and consultations with an

employer-sponsored employee assistance program (EAP) may be excluded unless the

consultations were for the applicant's substance abuse or unless the consultations

resulted in referral for psychiatric evaluation or treatment.

When an applicant does provide history in Item 19, the Examiner should review the

matter with the applicant. The Examiner will record in

Item 60, page 153 only that

information needed to document the review and provide the basis for a certification

decision. If the Examiner finds the information to be of a personal or sensitive nature

with no relevancy to flying safety, it should be recorded in

Item 60, page 153 as follows:

"Item 19. Reviewed with applicant. History not significant or relevant to

application."

If the applicant is otherwise qualified, a medical certificate may be issued by the

Examiner.

FAA medical authorities, upon review of the application, will ask for further information

regarding visits to health care providers only where the physical findings, report of

examination, applicant disclosure, or other evidence suggests the possible presence of

a disqualifying medical history or condition.

If an explanation has been given on a previous report(s) and there has been no change

in the condition, the applicant may enter "PREVIOUSLY REPORTED, NO CHANGE."

Of particular importance is the reporting of conditions that have developed since the

applicant's last FAA medical examination. The Examiner is asked to comment on all

entries, including those "PREVIOUSLY REPORTED, NO CHANGE." These comments

may be entered under

Item 60, page153.

LAST UPDATE: April 3, 2006

Guide for Aviation Medical Examiners

________________________________________________________________

ITEM 20. APPLICANT'S NATIONAL DRIVER REGISTER AND CERTIFYING

DECLARATION

NOTICE

20. Applicant’s National Driver Register and Certifying Declarations

I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to the FAA

information pertaining to my driving record. This consent constitutes authorization for a single access to the information contained in the

NDR to verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if

any, available for my review and written comment. Authority: 23 U.S. Code 401, Note.

NOTE: All persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an

application for Medical Certificate or Medical Certificate and Student Pilot Certificate.

I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my

knowledge, and I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and

understand the Privacy Act statement that accompanies this form.

Signature of Applicant Date

M M D D YYY Y

Whoever in any matter within the

jurisdiction of any department or

agency of the United States

knowingly and willfully falsifies,

conceals or covers up by any trick,

scheme, or device a material fact, or

who makes any false, fictitious or

fraudulent statements or

representations, or entry, may be

fined up to $250,000 or imprisoned

not more than 5 years, or both,

(18 U.S. Code Secs. 1001; 3571).

In addition to making a declaration of the completeness and truthfulness of the

applicant's responses on the medical application, the applicant's declaration authorizes

the National Driver Register to release the applicant's adverse driving history

information, if any, to the FAA. The FAA uses such information to verify information

provided in the application. The applicant should be instructed to sign Item 20 after

reading the declaration. The signature should be in ink. If an applicant does not sign

the declaration for any reason, the Examiner shall not issue a medical certificate but

forward the incomplete application to the AMCD.

LAST UPDATE: April 3, 2006