Name			ID#
Date of Birth		Gender male female	PI# optional
E-mail Address		Valid e-mail required
Phone
Has your medical ever been denied suspended or revoked?		No Yes            If yes, give details below
Class of medical desired First Second Third    Date of last medical application
			No prior application

Medication		Dosage	Condition Treated
Detail any loss of consciousness, injuries, major surgeries, or other condition which might limit physical activity or flying
Select all below which applies (Explain in the box below)
		Frequent or severe headaches
		Eye or vision trouble
		Hay fever or allergy
		Asthma or lung disease
		Stomach, liver, or intestinal trouble
		Kidney stone or blood in urine
		Neurological: epilepsy, seizures, stroke, etc
		Mental disorders: depression, anxiety, etc
		Dependence or use of illegal substance
		Alcohol dependence, abuse or related convictions
		Suicide attempt
		Motion sickness requiring medication
		Dizziness, fainting spells, or unconsciousness
EXPLAIN
		Diabetes No diabetes Taking injections On oral medication Controlled by diet
		HEART HISTORY
		Myocardial Infarction (Heart Attack)
		Angina, bypass, angioplasty
		Stroke / blood vessel surgery
		Other cardiovascular condition: