Nasa Competition License Physical Examination Instructions (Page 2 of 3) in pdf

APPLICANT’S MEDICAL HISTORY

(To be completed by applicant)

Applicant: For the purpose of obtaining a NASA Provisional License or a Competition License, complete this page legibly and in its entirety.

Failure to complete the information will delay the processing of your license. The examining physician must complete the second page of this

form. Note- the answer of “yes” for any condition highlighted below may be cause for review by the NASA Medical Director.

Name ______________________________________________________ Age ________ Date of Birth _______________

Address ________________________________________ City ______________________ St ____ Zip _______________

Email Address _________________________________________ Occupation ___________________________________

Phone (H) _____________________________ (W)____________________________ (C) __________________________

Personal Physician ______________________________________________ Phone ______________________________

Address ________________________________________ City ______________________ St ____ Zip _______________

Examining Physician ______________________________________________ Phone _____________________________

Address ________________________________________ City ______________________ St ____ Zip _______________

Please indicate if you have ever had, or have now, any of the following:

Conditions

Yes No

Conditions

Yes No

Frequent or severe headaches

Hay fever

Unconsciousness for any reason

Eye trouble (except glasses)

Dizziness or fainting spells

Asthma

Epilepsy or seizures

Diabetes

Coronary artery disease or angina

Anemia or other blood diseases including

Heart valve disease

abnormal bleeding

Left Bundle Brach Block (heart)

Admission to a hospital in the past 12

Abnormal cardiac rhythms

months

High blood pressure

Allergy(s) to medications

Any drug, narcotic, or alcohol problems

List:

Psychiatric/ mental health problems

Amputations / physical disability

Operation(s) on brain

Previous denial(s) from NASA, SCCA, or

Operation(s) on heart

other sanctioning body due to medical

Operation(s) on eyes, nerves, blood vessels,

reasons

or bone

Illness(es) not listed above

List:

Previous waiver(s) from NASA for medical

condition(s)

List:

NOTE- THE ANSWER OF “YES” TO ANY HIGHLIGHTED ABOVE WILL AUTOMATICALLY REQUIRE

A REVIEW BY THE NASA MEDICAL DIRECTOR.

Date of last Tetanus ________________ Blood Type ___________ Blood Thinner Medication (circle)

YES

Comments and details of any condition noted above _______________________________________________________

__________________________________________________________________________________________________

Medications Used (including eye drops) _________________________________________________________________

__________________________________________________________________________________________________

I certify that the above is true and correct information. I also give my permission for the NASA administration to access and/ or

exchange information with health care providers as well as the medical administration of other sanctioning bodies.

Applicant’s Signature _________________________________________________________ Date ___________________

Nasa Competition License Physical Examination Instructions Page 2

Related Articles

Related forms

Related Categories