Comprehensive Medical Examination Checklist
• "Substance dependence" is defined by any of the following: increased tolerance, withdrawal
symptoms, impaired control of use, or continued use despite damage to health, or impairment of
social, personal, or occupational functioning.
• "Substance abuse" is defined as the following: use of an illegal substance, use of a substance or
substances in situations in which such use is physically hazardous, or misuse of a substance when
such misuse has impaired health or social or occupational functioning.
18. v. CONVICTION, AND/OR ADMINISTRATIVE ACTION HISTORY:
(1) Have you ever been convicted (which may include paying a fine or forfeiting bond or collateral) of an
offense involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a
drug;
or
(2) Have you ever been convicted, and/or subject to an administrative action by a state or other jurisdiction
for an offense for which your driver's license was denied, suspended, cancelled, or revoked or which
resulted in attendance at an educational or rehabilitation program? Individual traffic convictions are not
required to be reported if they did not involve alcohol/drugs, suspension, revocation, cancellation, or denial
of driving privileges, or attendance at an educational or rehabilitation program. If "Yes" is checked, you
must give a description of the conviction(s) and/or administrative action(s) in the “additional comments or
explanation” box. The description must include:
• The alcohol or drug offense for which you were arrested and/or convicted or the type of
administrative action involved (e.g., attendance at an alcohol treatment 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(s) and/or administrative action(s). The FAA may check state motor
vehicle driving licensing records to verify your responses.
w. HISTORY OF NON-TRAFFIC CONVICTIONS(S) (MISDEANORS OR FELONIES): Have you ever
had any other (non-traffic) convictions (e.g., assault, battery, public intoxication, robbery, etc.)? If so,
name the charge for which you were convicted and the date of conviction in the
“additional comments or explanation" box.
19. VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS:
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. List
visits for counseling only if it was related to a personal substance abuse or psychiatric condition.
Enter the date of visit as month and year (e.g., 01/1990), name, address, and type of health
professional consulted and briefly state reason for consultation. Repeat this process to add all
relevant visits to medical professionals in the past 3 years. Multiple visits to one health
professional for the same condition may be grouped together on one line. You do not need to
report:
o Occasional common illnesses such as colds or sore throats that resolved;
o Routine dental, eye, and FAA periodic medical examinations; or
o Consultations with your employer-sponsored employee assistance program (EAP) unless
the consultations were for substance abuse or unless the consultations resulted in referral
for psychiatric evaluation or treatment.
NOTE: After compl
eting SECTION 2, carefully review and read the affirmation statements under the “Airman’s
Signature and Declarations.” If you agree with the statements, sign and date the document. Once you have
completed, signed, and dated SECTION 2, you must provide ALL sections (SECTION 1-3) of this checklist to
the state-licensed physician who will perform and complete the comprehensive medical examination, as
required by Section 2307(a)(7) of FAA Extension, Safety, and Security Act of 2016 (FESSA).
FAA 8700-2 Comprehensive Medical Examination Checklist (04-17)
4
18.