FAA Medical Practice Test / Pre-certification Screening Test

	Pilot Medical Solutions, Inc.Ž \| 800-699-4457
	Testimony \| FAQ \| Conditions \| Medications \| Evaluation \| AME's \| Contact

Confidential FAA Medical Practice Test	Exam Checklist
No information will be divulged to anyone without your consent.
This test is designed to identify areas which may jeopardize FAA medical certification or that will require extensive documentation prior to approval. It should be used as a Pre-Certification screening tool and is not intended as a substitute for a physicians examination or advice.

Name Optional

Age       Gender

E-mail Address Valid e-mail required

Phone Optional

Has your medical been denied,
suspended or revoked?

        If "YES", please give details below.

Class of medical desired

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?

HEART HISTORY

Myocardial Infarction (Heart Attack)

Angina, bypass, angioplasty

Stroke / blood vessel surgery

Other heart condition    List

Blood Pressure

For a confidential FAA medical consultation
Call 800-699-4457