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FAA Medical Support for Pilots and AME's

 

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
   
IS THIS TEXT BLACK OR WHITE?
   

           

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

FAA Medical Certification and Aviation Medicine Support for pilots and aviation medical examiners.

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