Medical Report
Medical Report
MEDICAL REPORT
(CONFIDENCIAL)
Initial
Medical Examination Place Date
Renewal
1 FULL NAME (Block Letters, Surname first) Mr./ Mrs. / Ms.
8 If involved in an Aircraft accident since last Medical Examination give date and location,
10 Any medication presently being prescribed? YES / NO If YES give description, purpose and by whom prescribed.
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11 Have you ever been treated for Alcoholism/Drug Addiction? ..…..... Do you Smoke?…………………. How much per Day / Week? …………....
12a Medical History - have you a History of any of the following - if Yes please tick and describe in Remarks
(a) Frequent or Severe Headaches (g) High or Low Blood Pressure (m) Motion Sickness requiring Drugs
(b) Dizziness, Fainting or Unconsciousness (h) Stomach Trouble (n) Discharge on Medical grounds from Service
(c) Eye Trouble (i) Kidney Stone or Blood in Urine (o) Head Injury
(d) Hay Fever (j) Sugar or Albumin in Urine (p) Heart Trouble
(e) Asthma (k) Epilepsy or Fits (q) Nervous Trouble of any sort
12b Family History – is there a history of any of the following in your family - if Yes please tick and describe in Remarks
(a) Epilepsy (c) Tuberculosis (e) Inherited Disorder
(b) Diabetes (d) Mental Illness (f) Glaucoma
12c Have you ever been refused medical assessment or had your assessment revoked or suspended. If so please give reasons belo w:
Remarks:
13 Brief details of any Illness, Accident, Disability or Admission to Hospital since last Medical Examination (or in the six months preceding initial examination).
Date(s) Details Doctor’s Name and Address
14 Declaration
I hereby declare that I have carefully considered the statements made above and that to the best of my belief they are complete and correct and that I have not
withheld any relevant information or made any misleading statement. I understand that if I have, with intent to deceive, made any false representation for the
purpose of procuring for myself a medical certificate, I may be guilty of a criminal offence.
Address ………………………………………………………………………………….
15 Routine ECG, CXR Reports and other tests reports and tracings should be securely attached to this examination report. AMEs ar e advised to retain copies of
reports for future reference.
AMEs comments including recommendation for further progress reports, specialist consultations should be submitted on a separate sheet of paper.
16 Height (Inches / cm) 17 Weight (Kgs / lbs) 18 Chest 19 Waist (Inches / cm)
Insp. in .............................. cm
Exp. in ........................... cm
20 Identifying Marks, Scars, Tattoos, Deformities: 21 Date of last:
Colour of hair: ECG
Colour of eyes: CXR
Physical Impression Audio
LEFT
Does the Candidate Possess Glasses YES / NO