Form Cg-719k - Medical Evaluation Report Page 4
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9Page 4 of 9 of CG-719K Rev. 01-09
Section III -
Medications
(must be completed by applicant and reviewed by verifying medical practitioner)
Credential applicants who are required to complete a general medical exam are required to report all prescription
medications prescribed, filled or refilled and/or taken within 30 days prior to the date that the applicant signs the CG-
719K. In addition, all prescription medications, and all non-prescription (over-the-counter)
medications including dietary supplements and vitamins, that were used for a period of 30 or more days within the last
90 days prior to the date that the applicant signs the CG-719K or approved equivalent form, must also be reported.
The information reported by the applicant must be verified by the verifying medical practitioner or other qualified
medical practitioner to the satisfaction of the verifying medical practitioner to include the following two items.
1.
Report all medications (prescription and non-prescription), dietary supplements, and vitamins.
2.
Include dosages of every substance reported on this form, as well as the condition for which each substance
is taken.
Additional sheets may be added by the applicant and/or qualified medical practitioner if needed to complete this
section (include applicant name and date of birth on each additional sheet).
If none, check “NONE.”
NONE
Section IV - Certification of Medical Conditions
(must be completed by applicant and reviewed by
verifying medical practitioner)
Applicants must report their relevant medical conditions to the best of their knowledge, and the verifying medical
practitioner must verify the medical conditions, using the table below. Check "yes" if the applicant has had a previous
diagnosis or treatment of the condition by a healthcare provider, or if the applicant is currently under treatment or
observation for the condition, or if the condition is present regardless of treatment.
If the verifying medical practitioner, or any other health care provider to the satisfaction of the verifying medical
practitioner, discovers a condition not reported by the applicant, he/she must check "yes" in the appropriate block and
explain in the remarks.
The verifying medical practitioner must address all reported relevant conditions in detail in this Section. This
detailed explanation should include, at a minimum, identification of the condition, approximate date of diagnosis, any
limitations, whether the condition is controlled, the prognosis and any additional information as appropriate, referring to
the evaluation data listed in enclosure
(3) of NVIC 4-08
for each condition.
Additional sheets may be added by the applicant and/or verifying medical practitioner if needed to complete this
section of the form. (include applicant name and DOB on each additional sheet).
To the best of the applicant’s knowledge, does the applicant have, or have ever suffered from, any of the
following?
If YES, the applicant must PROVIDE THE TEST RESULTS AND/OR RECORDS AS INDICATED, referring to the
evaluation data listed in enclosure
(3) of NVIC 4-08
for each condition. Documentation of evaluation data specified in
this table for all applicable medical conditions potentially requiring further review should be submitted with each
application, unless otherwise specified by the NMC. Mariners, including first class pilots and those individuals “serving
as” pilots (as well as Great Lakes pilots) who are required to submit annual physical examinations to the Coast Guard,
may be issued a letter by the NMC specifying the extent of the evaluation data, if any, that should be submitted to the
Coast Guard for any medical conditions that have been previously reported to, and evaluated by, the NMC.
The verifying medical practitioner shall make comments on all answers marked “yes” on the following page for which no
evaluation data has been submitted. If known to the VMP, the VMP may comment that a condition has been previously
reported on a prior CG-719K, but only for those CG-719Ks submitted after December 31, 2008, and only for those
conditions which have not changed since the condition was previously reported on a prior CG-719K.
Applicant Name: _______________________________________
Date of Birth:____________________________
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