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concussion
124 A positive HIV test 140 Heart disease
103 Spectacle/contact
lens prescriptions/change
since last medical exam
114 Frequent or severe
headaches
125 Sexually transmitted
disease
141 High blood pressure
104 Hay fever, other
allergy
115 Dizziness or fainting
spells
126 Admission to hospital 142 High cholesterol level
105 Asthma, lung disease 116 Unconsciousness for
any reason
127 Any other illness or
injury
143 Epilepsy
106 Heart or vascular
disease
117 Neurological disorders;
stroke, epilepsy, seizure,
paralysis, etc
128 Visit to medical
practitioner since last
medical examination
144 Mental illness
107 High or low blood
pressure
118
Psychological/psychiatric
disorder of any sort
129 Refusal of life insurance 145 Diabetes
146 Tuberculosis
108 Kidney stone or blood
in urine
119 Alcohol/drug/substance
abuse
130 Refusal of issue or
revocation of aviation
licence
147 Allergy/asthma/eczema
148 Inherited disorders
109 Diabetes, hormone
disorder
120 Attempted suicide 131 Medical rejection from
or for military service
149 Glaucoma
110 Stomach, liver or
intestinal disease
121 Motion sickness
requiring medication
132 Award of pension or
compensation for injury or
illness
Females only:
150 Gynaecological
disorders(including
menstrual)
111 Deafness, ear disease 122 Anaemia/Sickle cell
trait/other blood disorders
151 Are you pregnant?
(152) Remarks: If previously reported and unchanged, so state.
(32) DECLARATION: I hereby declare that I have carefully considered the statements I have made above and that to the best of my belief
they are complete and correct. I further declare that I have not withheld any relevant information or made any misleading statements. I
understand that if I have made any false or misleading statement in connection with this application, or if I do not consent to release the
supporting medical information, the Authority may refuse to grant me a Medical Assessment or may withdraw any Medical Assessment
granted, without prejudice to any other legal action applicable pursuant to [insert relevant national law].
CONSENT TO RELEASE OF MEDICAL INFORMATION: I hereby give my consent that all relevant medical information may be released
and submitted to the Medical Assessor of the Licensing Authority. Note: Medical confidentiality will be respected at all times.
................................................................................... .......................................................................................... ...................................................................................
Date Signature of applicant Signature of medical examiner (Witness)
INSTRUCTION PAGE FOR COMPLETION OF THE APPLICATION FORM
FOR AN AVIATION MEDICAL ASSESSMENT
This Application Form, all attached Report Forms and Reports are required in accordance with ICAO Annex 1 and will be transmitted to the Medical Assessor of
the Licensing Authority. Medical Confidentiality will be respected at all times.
The Applicant must personally complete in full all questions (boxes) on the Application Form. Writing must be in Block letters with a black ball-point pen and must
be legible. Exert sufficient pressure to make legible copies. If more space is required to answer any question, use a plain sheet of paper with the additional
information, your signature and the date. The following numbered instructions apply to the numbered headings on the application form.
NOTICE: Failure to complete the application form in full or to write legibly will result in the application form not being accepted. The making of False or
Misleading statements or the Withholding of relevant information in respect of this application may result in criminal prosecution, refusal of this application and/or
withdrawal of any Medical Assesssment/s previously granted.
1. SURNAME:
State Surname/ Family name.
17. LAST MEDICAL EXAMINATION:
State date (day/month/year) and place (city/town and country) of last aviation medical
examination. Initial applicants state ‘None’
2. PREVIOUS SURNAME(S):
If your surname or family name has been changed for any reason, state
previous name(s)
18. AVIATION LICENCE(S) HELD (TYPE). LICENCE NUMBER(S). COUNTRY(IES) OF
ISSUE:
Provide information concerning licences already held
19. FAMILY PHYSICIAN’S NAME AND ADDRESS (if applicable):
Provide contact details of family physician
3. NATIONAL IDENTIFICATION NUMBER (if applicable):
State your national identification number or social security number allocated to
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Manual of Civil Aviation Medicine 1(46)
