Application For Airman Medical Certificate Faa 8500-8 (Page 3 of 3) in pdf

NOTE: FAA/Original Copy of the Report of Medical Examination Must Be TYPED.

REPORT OF MEDICAL EXAMINATION

21. Height (inches)

22. Weight (pounds) 23. Statement of Demonstrated Ability (SODA)

24. SODA Serial Number

G Yes

G No

Defect Noted:

CHECK EACH ITEM IN APPROPRIATE COLUMN

Normal

Abnormal

CHECK EACH ITEM IN APPROPRIATE COLUMN

Normal

Abnormal

25. Head, face, neck, and scalp

37. Vascular system

(Pulse, amplitude and character; arms, legs, others)

26. Nose

38. Abdomen and viscera

(Including hernia)

27. Sinuses

39. Anus

(Not including digital examination)

28. Mouth and throat

40. Skin

29. Ears, general

41. G-U system

(Internal and external canals; Hearing under item 49)

(Not including pelvic examination)

30. Ear Drums

42. Upper and lower extremities

(Perforation)

(Strength and range of motion)

31. Eyes, general

43. Spine, other musculoskeletal

(Vision under items 50 to 54)

32. Ophthalmoscopic

44. Identifying body marks, scars, tattoos

(Size and location)

33. Pupils

45. Lymphatics

(Equality and reaction)

(Tendon reflexes, equilibrium, senses,

34. Ocular motility

46. Neurologic

(Associated parallel movement, nystagmus)

cranial nerves, coordination, etc.)

35. Lungs and chest

47. Psychiatric

(Not including breast examination)

(Appearance, behavior, mood, communication, and memory)

36. Heart

48. General systemic

(Precordial activity, rhythm, sounds, and murmurs)

NOTES: Describe every abnormality in detail. Enter applicable item number before each comment. Use additional sheets if necessary and attach to this form.

49. Hearing

Record Audiometric Speech

Right Ear

Left Ear

Discrimination Score Below

Conversational

Audiometer

500

1000

2000

3000

4000

500

1000

2000

3000

4000

Voice Test at 6 Feet

Threshold in

Decibels

G Pass

G Fail

50. Distant Vision

51.a. Near Vision

51.b. Intermediate Vision – 32 Inches

52. Color Vision

20/

Corrected to 20/

20/

Corrected to 20/

20/

Corrected to 20/

Right

Pass

20/

Corrected to 20/

20/

Corrected to 20/

20/

Corrected to 20/

Left

Fail

Both

20/

Corrected to 20/

Both

20/

Corrected to 20/

Both

20/

Corrected to 20/

53. Field of Vision

54. Heterophoria 20'

Esophoria

Expophoria

Right Hyperphoria

Left Hyperphoria

(in prism diopters)

Normal

Abnormal

55. Blood Pressure

56. Pulse

57. Urinalysis

58. ECG

(if abnormal, give results)

(Date)

(Resting)

Systolic

Diastolic

Albumin

Sugar

M M D D

Y Y Y Y

(Sitting,

Normal

Abnormal

mm of Mercury)

59. Other Tests Given

60. Comments on History and Findings: AME shall comment on all "YES" answers in the Medical History section and for

FOR FAA USE

abnormal findings of the examination. (Attach all consultation reports, ECGs, X-rays, etc. to this report before mailing.)

Pathology Codes:

Coded By:

Clerical Reject

Significant Medical History

YES

Abnormal Physical Findings

YES

61. Applicant's Name

62. Has Been Issued -- G Medical Certificate

G Medical & Student Pilot Certificate

No Certificate Issued -- Deferred for Further Evaluation

Has Been Denied -- Letter of Denial Issued (Copy Attached)

63. Disqualifying Defects (List by item number)

64. Medical Examiner's Declaration -- I hereby certify that I have personally reviewed the medical history and personally examined the applicant named

on this medical examination report. This report with any attachment embodies my findings completely and correctly.

Date of Examination

Aviation Medical Examiner's Name

Aviation Medical Examiner's Signature

M M

D D Y Y Y Y

Street Address

AME Serial Number

City

State

Zip Code

AME Telephone (