Nasa Competition License Physical Examination Instructions Page 3
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3PHYSICIAN’S EXAMINATION
(To be completed by a medical doctor)
Note- There are THREE PAGES to this form. Please see “APPLICANT’S MEDICAL HISTORY,” and “NASA Competition
License Physical Examination Instructions.”
Applicant’s Name __________________________________________________________ Date _____________________
Age ______ Sex ______ Height _______ Weight _________ Hair Color ______________ Eye Color __________
Blood Pressure ___ / ____ Pulse ______ Respirations ________
Note: Applicant’s having the following conditions must be referred to the NASA Medical Director for review:
1. Less than 20/40 corrected vision in the better eye
5. Loss of extremity or eye
9. Epilepsy
2. Alcohol or drug addiction
6. Diabetes
10. Implanted Defibrillator
3. All gross deformities subject to listing
7. Loss of color vision
11. Coronary Artery Disease/Stent/CABG/or MI
4. Blood pressure: Diastolic over 90 or systolic over 160 8. Psychological problems
12. History of Cardiac Arrhythmias
13. History of Syncope
VISION
Abnormalities require an attached ophthalmological consult
Vision OD __________ OS __________ OU __________
Color Vision ______________ Test _________________
Peripheral Vision (degrees from midline) ____________ OD __________ OS __________ Test ______________________
NEUROLOGICAL
Abnormalities require an attached neurological consult
Reflexes _____Normal _____Abnormal
Cerebellar _____Normal _____Abnormal
Other test performed ________________________________________________________________________________
CARDIAC
Abnormalities require an attached cardiologic consult
At the age of 40, a baseline EKG should be performed. Further EKG’s need to be completed only if the applicant is a smoker, has a
cardiac history, a strong family history of cardiac disease, history of diabetes, or has hypertension
(systolic > 140 or diastolic > 90).
Cardiac Exam _____Normal _____Abnormal
Please attach a copy of the EKG results.
METABOLIC
Please attach an HgbA1C and Endocrinologic consult for any history of diabetes.
History of diabetes ________Yes ________No
HgbA1C (less than 10) __________________________________
Comments or concerns regarding past or present health, and / or medications (and side effects), that the NASA Medical Director
should be aware of: ___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
On the basis of this limited examination, review of APPLICANT’S MEDICAL HISTORY, and the instructions addressed to me, I conclude
the following:
PASS:
FAIL or REVIEW:
Applicant is fit for motor racing
Applicant referred to NASA Medical Director
Signature ____________________________________
Printed Name ________________________________
Printed Name ________________________________
Address _____________________________________
Address _____________________________________
City ___________________ St _____ Zip __________
City ___________________ St _____ Zip __________
Phone Number ________________________
Phone Number ________________________
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