ATCO.AR.F.005 Medical certificate
Regulation (EU) 2015/340
The medical certificate shall conform to the following specifications:
(a) Content:
(1) State in which the ATCO licence has been issued or applied for (I);
(2) Class of medical certificate (II);
(3) Certificate number commencing with the UN country code of the state in which the ATCO licence has been issued or applied for and followed by a code of numbers and/or letters in Arabic numerals and Latin script (III);
(4) Name of the holder (IV);
(5) Nationality of the holder (VI);
(6) Date of birth of the holder (XIV);
(7) Signature of the holder (VII);
(8) Limitation(s) (XIII);
(9) Expiry date of the class 3 medical certificate (IX);
(10) Date of examination;
(11) Date of last electrocardiogram;
(12) Date of last audiogram;
(13) Date of issue and signature of AME or medical assessor that issued the medical certificate (X);
(14) Seal or stamp.
(b) Material: The paper or other material used shall prevent or readily show any alterations or erasures. Any entries or deletions to the form shall be clearly authorised by the competent authority.
(c) Language: Medical certificates shall be written in the national language(s) and in English and in such a language that the competent authority deems appropriate.
(d) All dates on the medical certificate shall be written in a dd/mm/yyyy format.
AMC1 ATCO.AR.F.005 Medical certificate
ED Decision 2015/010/R
STANDARD MEDICAL CERTIFICATE FORMAT
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Competent authority’s name and logo (English and any language(s) determined by the competent authority)
EUROPEAN UNION (English only)
Class 3 MEDICAL CERTIFICATE Pertaining to a Part ATCO licence (English and any language(s) determined by the competent authority)
Issued in accordance with Part ATCO.MED
This medical certificate complies with the ICAO Standards
(English and any language(s) determined by the competent authority)
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Requirements:
‘European Union’ to be deleted for non-EU Member States.
The size of each page should be one eighth A4.
English and any language(s) determined by the competent authority. |
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I Authority that issued or is to issue the ATCO licence:
III Certificate number:
IV Last and first name of holder:
XIV Date of birth: (dd/mm/yyyy)
VI Nationality:
VII Signature of holder: |
XIII Limitations: Code: Description:
X Date of issue*:
Signature of issuing AME/medical assessor:
XI Stamp:
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2 |
3 |
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IX Expiry date of this certificate: |
dd/mm/yyyy |
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Examination date: (dd/mm/yyyy)
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4 |
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* Date of issue is the date when the certificate is issued and signed.
Regulation (EU) 2015/340
After having verified that the AME is in compliance with the applicable requirements, the competent authority shall issue, revalidate, renew or change the AME certificate using the form established in Appendix 3 of Annex II.
ATCO.AR.F.015 AeMC certificate
Regulation (EU) 2015/340
After having verified that the AeMC is in compliance with the applicable requirements, the competent authority shall issue or change the AeMC certificate, using the form established in Appendix 4 of Annex II.
ATCO.AR.F.020 Aero-medical forms
Regulation (EU) 2015/340
The competent authority shall provide AMEs and AeMCs with the forms to be used for:
(a) the application form for a medical certificate; and
(b) the examination report form for class 3 applicants.
AMC1 ATCO.AR.F.020 Aero-medical forms
ED Decision 2015/010/R
AERO-MEDICAL FORMS
The forms referred to in ATCO.AR.F.020 should reflect the information indicated in the following forms and corresponding instructions for completion.
LOGO
CIVIL AVIATION ADMINISTRATION/MEMBER STATE
APPLICATION FORM FOR A MEDICAL CERTIFICATE
MEDICAL IN CONFIDENCE
Complete this page fully and in block capitals — Refer to instructions for completion.
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(1) State of licence issue: |
(2) Medical certificate applied for: Class 1 Class 2 Class 3 |
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(3) Surname: |
(4) Previous surname(s): |
(12) Application:
Initial |
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(5) Forename(s): |
(6) Date of birth (dd/mm/yyyy):
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(7) Sex:
Male |
(13) Reference number: |
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(8) Place and country of birth: |
(9) Nationality: |
(14) Type of licence applied for: |
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(10) Permanent address:
Country: Telephone No: Mobile No: E-mail: |
(11) Postal address (if different):
Country: Telephone No: |
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(15) Occupation (principal): |
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(16) Employer: |
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(17) Last aero-medical examination: Date: Place: |
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Licence(s) number(s):
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(19) Any limitations on licence(s)/medical certificate held: No Yes Details: |
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(20) Have you ever had a medical certificate denied, suspended or revoked? No Yes Date: Country: Details: |
(21) Flight time total:
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(22) Flight time since last aero-medical examination: |
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(23) Aircraft class/type(s) currently flown: n/a |
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(24) Any aviation accident or reported incident since last aero-medical examination? No n/a Yes Date: Place: Details: |
(25) Type of flying intended: n/a |
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(26) Current pilot activity: Single pilot Multi-pilot Current ATCO activity: ADI APS ACS |
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(27) Do you drink alcohol? No Yes If yes, amount |
(28) Do you currently use any medication? No Yes state medication, dose, date started and why: |
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(29) Do you smoke tobacco? No, never No, stopped state date: Yes state type and amount: |
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General and medical history: Do you have, or have you ever had, any of the following? (Please tick). If yes, give details in the remarks section (30).
Yes No Yes No Yes No Family history of: Yes No
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101 Eye trouble/eye operation |
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112 Nose, throat or speech disorder |
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123 Malaria or other tropical disease |
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170 Heart disease |
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102 Spectacles and/or contact lenses ever worn |
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113 Head injury or concussion |
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124 A positive HIV test |
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171 High blood pressure |
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114 Frequent or severe headaches |
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125 Sexually transmitted disease |
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172 High cholesterol level |
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103 Spectacle/contact lens prescriptions change since last medical exam. |
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115 Dizziness or fainting spells |
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126 Sleep disorder/apnoea syndrome |
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173 Epilepsy |
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116 Unconsciousness for any reason |
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127 Musculoskeletal illness/impairment |
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174 Mental illness |
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104 Hay fever, other allergy |
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117 Neurological disorders: stroke, epilepsy, seizure, paralysis, etc. |
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128 Any other illness or injury |
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175 Diabetes |
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105 Asthma, lung disease |
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129 Admission to hospital |
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176 Tuberculosis |
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106 Heart or vascular trouble |
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118 Psychological/ psychiatric trouble of any sort |
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130 Visit to medical practitioner since last aero-medical examination |
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177 Allergy/ asthma/eczema |
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107 High or low blood pressure |
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178 Inherited disorders |
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108 Kidney stone or blood in urine |
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119 Alcohol/drug/ substance abuse |
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131 Refusal of life insurance |
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179 Glaucoma |
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109 Diabetes, hormone disorder |
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120 Attempted suicide |
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132 Refusal of pilot/ATCO licence |
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Females only: |
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110 Stomach, liver or intestinal trouble |
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121 Motion sickness requiring medication |
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133 Medical rejection from or for military service |
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150 Gynaecological, menstrual problems |
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111 Deafness, ear disorder |
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122 Anaemia/sickle cell trait/other blood disorders |
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134 Award of pension or compensation for injury or illness |
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151 Are you pregnant? |
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(30) Remarks: If previously reported and no change since, so state. |
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(31) Declaration: I hereby declare that I have carefully considered the statements made above and to the best of my belief they are complete and correct and that I have not withheld any relevant information or made any misleading statements. I understand that if I have made any false or misleading statements in connection with this application, or fail to release the supporting medical information, the licensing authority may refuse to grant me a medical certificate or may withdraw any medical certificate granted, without prejudice to any other action applicable under national law. CONSENT TO RELEASE OF MEDICAL INFORMATION: I hereby authorise the release of all information contained in this report and any or all attachments to the AME and, where necessary, to the medical assessor of the licensing authority, recognising that these documents or electronically stored data are to be used for completion of a medical assessment and will become and remain the property of the licensing authority, providing that I or my physician may have access to them according to national law. Medical confidentiality will be respected at all times.
------------------------------------ -------------------------------------------- -------------------------------------------- Date Signature of applicant Signature of AME/(medical assessor) |
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INSTRUCTIONS FOR COMPLETION OF THE APPLICATION FORM FOR A MEDICAL CERTIFICATE
This application form and all attached report forms will be transmitted to the licensing authority. Medical confidentiality shall be respected at all times.
The applicant should personally complete, in full, all questions (sections) on the application form. Writing should be legible and in block capitals, using a ball-point pen. Completion of this form by typing/printing is also acceptable. If more space is required to answer any questions, a plain sheet of paper should be used, bearing the applicant’s name and signature, and the date of signing. The following numbered instructions apply to the numbered headings on the application form for a medical certificate.
Failure to complete the application form in full, or to write legibly, may result in non-acceptance of the application form. The making of false or misleading statements or the withholding of relevant information in respect of this application may result in criminal prosecution, denial of this application and/or withdrawal of any medical certificate(s) granted
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1. LICENSING AUTHORITY: State name of country this application is to be forwarded to. |
17. LAST APPLICATION FOR A MEDICAL CERTIFICATE:
State date (day, month, year) and place (town, country). |
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2. MEDICAL CERTIFICATE APPLIED FOR: Tick appropriate box. Class 1: Professional Pilot Class 2: Private Pilot Class 3: Air Traffic Controller |
18. LICENCE(S) HELD (TYPE): State type of licence(s) held. Enter licence number and State of issue. If no licences are held, state ‘NONE’. |
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3. SURNAME: State surname/family name. |
19. ANY LIMITATIONS ON THE LICENCE(S)/MEDICAL CERTIFICATE: Tick appropriate box and give details of any limitations on your licence(s)/medical certificate, e.g. vision, colour vision, safety pilot, etc. |
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4. PREVIOUS SURNAME(S): If your surname or family name has changed for any reason, state previous name(s). |
20. MEDICAL CERTIFICATE DENIAL, SUSPENSION OR REVOCATION: Tick ‘YES’ box if you have ever had a medical certificate denied, suspended or revoked, even if only temporary. If ‘YES’, state date (dd/mm/yyyy) and country where it occurred. |
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5. FORENAME(S): State first and middle names (maximum three). |
21. FLIGHT TIME TOTAL: State total number of hours flown or, for ATCO’s tick n/a box. |
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6. DATE OF BIRTH: Specify in order dd/mm/yyyy. |
22. FLIGHT TIME SINCE LAST MEDICAL: State number of hours flown since your last aero-medical examination or, for ATCO’s tick n/a box. |
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7. SEX: Tick appropriate box. |
23. AIRCRAFT CLASS/TYPE(S) CURRENTLY FLOWN: State name of principal aircraft flown, e.g. Boeing 737, Cessna 150, etc. or, for ATCO’s tick n/a box. |
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8. PLACE AND COUNTRY OF BIRTH: State town and country of birth. |
24. ANY AVIATION ACCIDENT OR REPORTED INCIDENT SINCE LAST AERO-MEDICAL EXAMINATION: If ‘YES’ box ticked, state date (dd/mm/yyyy) and country of accident/incident. |
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9. NATIONALITY: State name of country of citizenship. |
25. TYPE OF FLYING INTENDED: State whether airline, charter, single pilot, commercial air transport, carrying passengers, agriculture, pleasure, etc., or, for ATCO’s tick n/a box. |
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10. PERMANENT ADDRESS: State permanent postal address and country. Enter telephone area code as well as telephone number. |
26. CURRENT PILOT/ATCO ACTIVITY: Tick appropriate box to indicate whether you fly as the SOLE pilot or not or, for ATCO’s whether you operate as tower, radar or other. |
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11. POSTAL ADDRESS (IF DIFFERENT): If different from permanent address, state full current postal address including telephone number and area code. If the same, enter ‘SAME’. |
27. DO YOU DRINK ALCOHOL?
Tick applicable box. If yes, state weekly alcohol consumption, |
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12. APPLICATION: Tick appropriate box. |
28. DO YOU CURRENTLY USE ANY MEDICATION? If ‘YES’, give full details — name, how much you take and when, etc. Include any non-prescription medication. |
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13. REFERENCE NUMBER: State reference number allocated to you by the licensing authority. Initial applicants enter ‘NONE’. |
29. DO YOU SMOKE TOBACCO? Tick applicable box. Current smokers state type (cigarettes, cigars, pipe) and amount (e.g. 2 cigars daily; pipe — 1 oz. weekly). |
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14. TYPE OF LICENCE APPLIED FOR: State type of licence applied for from the following list: — Aeroplane Transport Pilot Licence — Multi-Pilot Licence — Commercial Pilot Licence/Instrument Rating — Commercial Pilot Licence — Air Traffic Controller Licence — Private Pilot Licence/Instrument Rating — Private Pilot Licence — Sailplane Pilot Licence — Balloon Pilot Licence — and whether Fixed Wing/Rotary Wing/Both |
GENERAL AND MEDICAL HISTORY All items under this heading from number 101 to 179 inclusive should have the answer ‘YES’ or ‘NO’ ticked. You should tick ‘YES’ if you have ever had the condition in your life and describe the condition and approximate date in the (30) remarks section. All questions asked are medically important even though this may not be readily apparent. Items numbered 170 to 179 relate to immediate family history, whereas items numbered 150 to 151 should be answered by female applicants only. If information has been reported on a previous application form for a medical certificate and there has been no change in your condition, you may state ‘Previously reported; no change since’. However, you should still tick ‘YES’ to the condition. Do not report occasional common illnesses such as colds. |
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31. DECLARATION AND CONSENT TO OBTAINING AND RELEASING INFORMATION: Do not sign or date these declarations until indicated to do so by the AME who will act as witness and sign accordingly. |
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15. OCCUPATION (PRINCIPAL): Indicate your principal employment. |
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16. EMPLOYER: If principal occupation is pilot/ATCO, then state employer’s name or if self-employed as a pilot, state ‘self’. |
AERO-MEDICAL EXAMINATION REPORT FORM FOR CLASS 1, CLASS 2 & CLASS 3 APPLICANTS
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(201) Examination category Initial Revalidation Renewal |
(202) Height (cm) |
(203) Weight (kg) |
(204) Colour eye |
(205) Colour hair |
(206) Blood pressure — seated (mmHg) |
(207) Pulse — resting |
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Rate (bpm) |
Rhythm: regular irregular |
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Referral |
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Systolic |
Diastolic |
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Clinical exam: Check each item Normal Abnormal Normal Abnormal
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(208) Head, face, neck, scalp |
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(218) Abdomen, hernia, liver, spleen |
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(209) Mouth, throat, teeth, voice, speech |
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(219) Anus, rectum |
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(210) Nose, sinuses |
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(220) Genito-urinary system |
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(211) Ears, drums, eardrum motility |
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(221) Endocrine system |
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(212) Eyes — orbit & adnexa; visual fields |
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(222) Upper & lower limbs, joints |
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(213) Eyes — pupils and optic fundi |
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(223) Spine, other musculoskeletal |
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(214) Eyes — ocular motility; nystagmus |
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(224) Neurologic — reflexes, etc. |
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(215) Lungs, chest, breasts |
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(225) Psychiatric |
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(216) Heart |
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(226) Skin, identifying marks and lymphatics |
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(217) Vascular system |
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(227) General systemic |
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(228) Notes: Describe every abnormal finding. Enter applicable item number before each comment. |
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Visual acuity
(229) Distant vision (236) Pulmonary function (237) Haemoglobin
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Uncorrected |
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Spectacles |
Contact lenses |
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FEV1/FVC __________ % |
____________ ______ (unit) |
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Right eye |
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Corr. to |
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Left eye |
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Corr. to |
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Normal Abnormal |
Normal Abnormal |
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Both eyes |
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Corr. to |
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(235) Urinalysis Normal Abnormal |
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(230) Intermediate vision |
Uncorrected |
Corrected |
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Glucose |
Protein |
Blood |
Other |
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Yes |
No |
Yes |
No |
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Right eye |
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Accompanying reports |
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Left eye |
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Not performed |
Normal |
Abnormal/Comment |
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Both eyes |
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(238) ECG |
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(239) Audiogram |
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(231) Near vision |
Uncorrected |
Corrected |
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(240) Ophthalmology |
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Yes |
No |
Yes |
No |
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(241) ORL (ENT) |
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Right eye |
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(242) Blood lipids |
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Left eye |
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(243) Pulmonary function |
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Both eyes |
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(244) Other (what?) |
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(232) Spectacles |
(233) Contact lenses |
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Yes No |
Yes No |
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Type: |
Type: |
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(247) AME recommendation: |
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Refraction |
Sph |
Cyl |
Axis |
Add |
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Name of applicant: Date of birth: Reference number:
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Right eye |
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Left eye |
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Fit for class: -------------------- |
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(313) Colour vision |
Normal Abnormal |
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Medical certificate issued by undersigned (copy attached) for class: ------------------------------- |
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Colour vision testing method/s: |
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Unfit for class: -------------------- |
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Results: |
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Deferred for further evaluation. If yes, why and to whom? |
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(234) Hearing (when 239/241 not performed) |
Right ear |
Left ear |
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(248) Comments, limitations |
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Conversational voice test (2m) with back turned to examiner |
Yes No |
Yes No |
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Audiometry |
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Hz |
500 |
1000 |
2000 |
3000 |
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Right |
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Left |
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(249) AME declaration:
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I hereby certify that I/my AME group have personally examined the applicant named on this aero-medical examination report and that this report with any attachment embodies my findings completely and correctly. |
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(250) Place and date:
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AME name and address: |
AME certificate No: |
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AME signature: |
E-mail: |
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Telephone No: Telefax No: |
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INSTRUCTIONS FOR COMPLETION OF THE AERO-MEDICAL EXAMINATION REPORT FORMS
The AME performing the aero-medical examination should verify the identity of the applicant.
All questions (sections) on the aero-medical examination report form should be completed in full. If an otorhinolaryngology examination report form is attached, then questions 209, 210, 211, and 234 may be omitted. If an ophthalmology examination report form is attached, then questions 212, 213, 214, 229, 230, 231, 232, and 233 may be omitted.
Writing should be legible and in block capitals using a ball-point pen. Completion of this form by typing/printing is also acceptable. If more space is required to answer any question, a plain sheet of paper should be used, bearing the applicant’s name, the AME’s name and signature, and the date of signing. The following numbered instructions apply to the numbered headings on the aero-medical examination report form.
Failure to complete the aero-medical examination report form in full, as required, or to write legibly, may result in non-acceptance of the application in total and may lead to withdrawal of any medical certificate issued. The making of false or misleading statements or the withholding of relevant information by an AME may result in criminal prosecution, denial of an application or withdrawal of any medical certificate(s) granted.
201 EXAMINATION CATEGORY — Tick appropriate box.
Initial — Initial examination for either class 1, 2 or 3; also initial examination for upgrading from class 2 to 1 (notate ‘upgrading’ in box 248).
Renewal/Revalidation —Subsequent ROUTINE examinations.
202 HEIGHT — Measure height, without shoes, in centimetres to nearest cm.
203 WEIGHT — Measure weight, in indoor clothes, in kilograms to nearest kg.
204 COLOUR EYE — State colour of applicant’s eyes from the following list: brown, blue, green, hazel, grey, multi.
205 COLOUR HAIR — State colour of applicant’s hair from the following list: brown, black, red, fair, bald.
206 BLOOD PRESSURE — Blood pressure readings should be recorded as Phase 1 for systolic pressure and Phase 5 for diastolic pressure. The applicant should be seated and rested. Recordings in mm Hg.
207 PULSE (RESTING) — The pulse rate should be recorded in beats per minute and the rhythm should be recorded as regular or irregular. Further comments if necessary may be written in section 228, 248 or separately.
208 to 227 inclusive constitute the general clinical examination, and each of the boxes should be marked (with a tick) as normal or abnormal.
208 HEAD, FACE, NECK, SCALP — To include appearance, range of neck and facial movements, symmetry, etc.
209 MOUTH, THROAT, TEETH, VOICE, SPEECH — To include voice and speech quality and appearance of buccal cavity, palate motility, tonsillar area, pharynx and also gums, teeth and tongue.
210 NOSE, SINUSES — To include appearance and any evidence of nasal obstruction or sinus tenderness on palpation.
211 EARS, DRUMS, EARDRUM MOTILITY — To include otoscopy of external ear, canal, tympanic membrane. Eardrum motility by valsalva manoeuvre or by pneumatic otoscopy.
212 EYES — ORBIT AND ADNEXA; VISUAL FIELDS — To include appearance, position and movement of eyes and their surrounding structures in general, including eyelids and conjunctiva. Visual fields check by campimetry, perimetry or confrontation.
213 EYES — PUPILS AND OPTIC FUNDI — To include appearance, size, reflexes, red reflex and fundoscopy. Special note of corneal scars.
214 EYES — OCULAR MOTILITY, NYSTAGMUS — To include range of movement of eyes in all directions; symmetry of movement of both eyes; ocular muscle balance; convergence; accommodation; signs of nystagmus.
215 LUNGS, CHEST, BREASTS — To include inspection of chest for deformities, operation scars, abnormality of respiratory movement, auscultation of breath sounds. Physical examination of female applicant’s breasts should only be performed with informed consent.
216 HEART — To include apical heartbeat, position, auscultation for murmurs, carotid bruits, palpation for trills.
217 VASCULAR SYSTEM — To include examination for varicose veins, character and feel of pulse, peripheral pulses, evidence of peripheral circulatory disease.
218 ABDOMEN, HERNIA, LIVER, SPLEEN — To include inspection of abdomen; palpation of internal organs; check for inquinal hernias in particular.
219 ANUS, RECTUM — Examination only with informed consent.
220 GENITO-URINARY SYSTEM — To include renal palpation; inspection palpation male/female reproductive organs only with informed consent.
221 ENDOCRINE SYSTEM — To include inspection, palpation for evidence of hormonal abnormalities/imbalance; thyroid gland.
222 UPPER AND LOWER LIMBS, JOINTS — To include full range of movements of joints and limbs, any deformities, weakness or loss. Evidence of arthritis.
223 SPINE, OTHER MUSCULOSKELETAL — To include range of movements, abnormalities of joints.
224 NEUROLOGIC — REFLEXES, ETC. To include reflexes, sensation, power, vestibular system — balance, romberg test, etc.
225 PSYCHIATRIC — To include appearance, appropriate mood/thought, unusual behaviour.
226 SKIN, IDENTIFYING MARKS AND LYMPHATICS — To include inspection of skin; inspection, palpation for lymphadenopathy, etc. Briefly describe scars, tattoos, birthmarks, etc., which could be used for identification purposes.
227 GENERAL SYSTEMIC — All other areas, systems and nutritional status.
228 NOTES — Any notes, comments or abnormalities to be described — extra notes if required on separate sheet of paper, signed and dated.
229 DISTANT VISION — Each eye to be examined separately and then both together. First without correction, then with spectacles (if used) and lastly with contact lenses, if used. Record visual acuity in appropriate boxes. Visual acuity to be tested with the appropriate chart for the distance.
230 INTERMEDIATE VISION — Each eye to be examined separately and then both together. First without correction, then with spectacles, if used, and lastly with contact lenses, if used. Record visual acuity in appropriate boxes (Yes/No).
231 NEAR VISION — Each eye to be examined separately and then both together. First without correction, then with spectacles if used and lastly with contact lenses, if used. Record visual acuity in appropriate boxes (Yes/No).
Note: Bifocal contact lenses and contact lenses correcting for near vision only are not acceptable.
232 SPECTACLES — Tick appropriate box signifying if spectacles are or are not worn by applicant. If used, state type of lens and frame and use-distance.
233 CONTACT LENSES — Tick appropriate box signifying if contact lenses are or are not worn. If worn, state type from the following list; hard, soft, gas-permeable or disposable.
313 COLOUR VISION — Tick appropriate box signifying if applicant is a normal trichromat or not. Indicate the colour vision testing methodology used and provide the results.
234 HEARING — Tick appropriate box to indicate hearing level ability as tested separately in each ear at 2 m.
235 URINALYSIS — State whether result of urinalysis is normal or not by ticking appropriate box. If no abnormal constituents, state NIL in each appropriate box.
236 PULMONARY FUNCTION — When required or on indication, state actual FEV1/FVC value obtained in % and state if normal or not with reference to height, age, sex and race.
237 HAEMOGLOBIN — Enter actual haemoglobin test result and state units used. Then state whether normal value or not, by ticking appropriate box.
238 to 244 inclusive: ACCOMPANYING REPORTS — One box opposite each of these sections must be ticked. If the test is not required and has not been performed, then tick the NOT PERFORMED box. If the test has been performed (whether required or on indication) complete the normal or abnormal box as appropriate. In the case of question 244, the number of other accompanying reports must be stated.
247 AME RECOMMENDATION — The applicant’s name, date of birth and reference number, should be entered here in block capitals. The applicable class of medical certificate should be indicated by a tick in the appropriate box. If a fit assessment is recommended and a medical certificate has been issued, this should be indicated in the appropriate box. An applicant may be recommended as fit for a lower class of medical certificate (e.g. class 2), but also be deferred or recommended as unfit for a higher class of medical certificate (e.g. class 1). If an unfit recommendation is made, applicable Part MED/Part ATCO.MED paragraph references should be entered. If an applicant is deferred for further evaluation, the reason and the specialist or licensing authority to whom the applicant is referred should be indicated.
248 COMMENTS, LIMITATIONS, ETC. — The AME’s findings and assessment of any abnormality in the history or examination, should be entered here. The AME should also state any limitation required.
249 AME DETAILS — The AME should sign the declaration, complete his/her name and address in block capitals, contact details and lastly stamp the relevant section with his/her designated AME stamp incorporating his/her AME number.
250 PLACE AND DATE — The place (town or city) and the date of the aero-medical examination should be entered here. The date of examination is the date of the general examination and not the date of finalisation of the form. If the aero-medical examination report is finalised on a different date, the date of finalisation should be entered in section 248 as ‘Report finalised on ...’.
OPHTHALMOLOGY EXAMINATION REPORT FORM
Complete this page fully and in block capitals — Refer to instructions for completion.
MEDICAL IN CONFIDENCE
Applicant’s details
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(1) Licensing authority: |
(2) Medical certificate applied for: Class 1 Class 2 Class 3 |
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(3) Surname: |
(4) Previous surname(s): |
(12) Application: Initial Revalidation/Renewal |
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(5) Forename(s): |
(6) Date of birth: |
(7) Sex: Male Female |
(13) Reference number: |
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--------------------------------------- -------------------------------------------------- --------------------------------------------------- Date Signature of applicant Signature of AME |
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(302) Examination category: |
(303) Ophthalmological history: |
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Initial |
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Revalidation |
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Renewal |
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Referral |
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Clinical examination Visual acuity
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Check each item |
Normal |
Abnormal |
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(314) Distant vision
Uncorrected |
Spectacles
Contact |
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(304) Eyes, external & eyelids |
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Right eye |
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Corrected to |
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(305) Eyes, Exterior (slit lamp, ophth.) |
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Left eye |
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Corrected to |
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Both eyes |
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Corrected to |
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(306) Eye position and motility |
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(315) Intermediate vision
Uncorrected |
Spectacles
Contact |
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(307) Visual fields |
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Right eye |
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Corrected to |
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(308) Pupillary reflexes |
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Left eye |
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Corrected to |
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(309) Fundi (Ophthalmoscopy) |
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Both eyes |
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Corrected to |
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(310) Convergence |
cm |
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(316) Near vision
Uncorrected |
Spectacle
Contact |
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(311) Accommodation |
D |
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Right eye |
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Corrected to |
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Left eye |
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Corrected to |
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(312) Ocular muscle balance (in prisme dioptres) |
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Both eyes |
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Corrected to |
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Distant at 5m/6m |
Near at 30–50 cm |
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Ortho |
Ortho |
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(317) Refraction |
Sph |
Cylinder |
Axis |
Near (add) |
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Eso |
Eso |
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Right eye |
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Exo |
Exo |
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Left eye |
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Hyper |
Hyper |
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Actual refraction examined Spectacles prescription based |
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Cyclo |
Cyclo |
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Tropia Yes No Phoria Yes No |
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(318) Spectacles |
(319) Contact lenses |
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Fusional reserve testing Not performed Normal Abnormal |
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Yes No |
Yes No |
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(313) Colour vision |
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Type: |
Type: |
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Colour vision testing method/s: |
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Results: |
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(320) Intra-ocular pressure |
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Normal trichromat Yes No |
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Right (mmHg) |
Left (mmHg) |
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Method |
Normal Abnormal |
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(321) Ophthalmological remarks and recommendation:
(322) Examiner’s declaration:
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I hereby certify that I/my AME group have personally examined the applicant named on this medical examination report and that this report with any attachment embodies my findings completely and correctly. |
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(323) Place and date: |
Ophth. examiner’s name and address: (block capitals) |
AME or specialist stamp with No: |
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AME or specialist signature: |
E-mail: Telephone No: Telefax No: |
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INSTRUCTIONS FOR COMPLETION OF THE OPHTHALMOLOGY EXAMINATION REPORT FORM
Writing should be legible and in block capitals using a ball-point pen. Completion of this form by typing or printing is also acceptable. If more space is required to answer any question, a plain sheet of paper should be used, bearing the applicant’s name, the name and signature of the AME or ophthalmology specialist performing the examination and the date of signing. The following numbered instructions apply to the numbered headings on the ophthalmology examination report form.
Failure to complete the medical examination report form in full, as required, or to write legibly may result in non-acceptance of the application in total and may lead to withdrawal of any medical certificate issued. The making of false or misleading statements or the withholding of relevant information by an examiner may result in criminal prosecution, denial of an application or withdrawal of any medical certificate granted.
The AME or ophthalmology specialist performing the examination should verify the identity of the applicant. The applicant should then be requested to complete the sections 1, 2, 3, 4, 5, 6, 7, 12 and 13 on the form and then sign and date the consent to release of medical information (section 301) with the examiner countersigning as witness.
302 EXAMINATION CATEGORY — Tick appropriate box.
Initial — Initial examination for either class 1 or 2 or 3; also initial examination for upgrading from class 2 to 1 (notate ‘upgrading’ in section 303).
Renewal/Revalidation — Subsequent comprehensive ophthalmological examinations (due to refractive error).
Special referral — NON-ROUTINE examination for assessment of an ophthalmological symptom or finding.
303 OPHTHALMOLOGICAL HISTORY — Detail here any history of note or reasons for special referral.
304 to 309 inclusive: CLINICAL EXAMINATION — These sections together cover the general clinical examination and each of the sections should be marked (with a tick) as normal or abnormal. Any abnormal findings or comments on findings should be entered in section 321.
310 CONVERGENCE — Enter near point of convergence in cm, as measured using RAF near point rule or equivalent. Tick whether normal or abnormal. Any abnormal findings or comments on findings should be entered in section 321.
311 ACCOMMODATION — Enter measurement recorded in dioptres using RAF near point rule or equivalent. Tick whether normal or abnormal. Any abnormal findings or comments on findings should be entered in section 321.
312 OCULAR MUSCLE BALANCE — Ocular muscle balance is tested at distant 5 or 6 m and near at 30–50 cm and results recorded. Presence of tropia or phoria must be entered accordingly and also whether fusional reserve testing was NOT performed and if performed whether normal or not.
313 COLOUR VISION —Tick appropriate box signifying if applicant is a normal trichromat or not. Indicate the colour vision testing methodology used and provide results.
314–316 VISUAL ACUITY TESTING AT 5 m/6m, 1m and 30–50cm — Record actual visual acuity obtained in appropriate boxes. If correction not worn nor required, put line through corrected vision boxes. Distant visual acuity to be tested at either 5 m or 6 m with the appropriate chart for that distance.
317 REFRACTION — Record results of refraction. Indicate also whether for class 2 applicants, refraction details are based upon spectacle prescription.
318 SPECTACLES — Tick appropriate box signifying if spectacles are or are not worn by applicant. If used, state whether unifocal, bifocal, varifocal or look-over.
319 CONTACT LENSES — Tick appropriate box signifying if contact lenses are or are not worn. If worn, state type from the following list; hard, soft, gas-permeable, disposable.
320 INTRA-OCULAR PRESSURE — Enter intra-ocular pressure recorded for right and left eyes and indicate whether normal or not. Also indicate method used —applanation, air, etc.
321 OPHTHALMOLOGICAL REMARKS AND RECOMMENDATION — Enter here all remarks, abnormal findings and assessment results. Also enter any limitations recommended. If there is any doubt about findings or recommendations, the examiner may contact the medical assessor for advice before finalising the report form.
322 OPHTHALMOLOGY EXAMINER’S DETAILS — The ophthalmology examiner must sign the declaration, complete his/her name and address in block capitals, contact details and lastly stamp the report with his/her designated stamp incorporating his/her AME or specialist number.
323 PLACE AND DATE — Enter the place (town or city) and the date of examination. The date of examination is the date of the clinical examination and not the date of finalisation of form. If the ophthalmology examination report is finalised on a different date, enter date of finalisation on section 321 as ‘Report finalised on...’.
OTORHINOLARYNGOLOGY EXAMINATION REPORT FORM
Complete this page fully and in block capitals — Refer to instructions for completion.
MEDICAL IN CONFIDENCE
Applicant’s details
|
(1) Licensing authority: |
(2) Medical certificate applied for: class 1 class 2 class 3 |
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(3) Surname: |
(4) Previous surname(s): |
(12) Application: Initial Revalidation/Renewal |
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(5) Forename(s): |
(6) Date of birth: |
(7) Sex: Male Female |
(13) Reference number: |
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(401) Consent to release of medical information: I hereby authorise the release of all information contained in this report and any or all attachments to the AME and, where necessary, to the medical assessor of the licensing authority, recognising that these documents, or any electronically stored data, are to be used for completion of a medical assessment and will become and remain the property of the licensing authority, providing that I or my physician may have access to them according to national law. Medical confidentiality will be respected at all times.
------------------------------------ ----------------------------------------------------- -------------------------------------------------- Date Signature of applicant Signature of AME |
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(402) Examination category: |
(403) Otorhinolaryngological history: |
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Initial Revalidation/renewal |
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Referral |
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Clinical examination
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Check each item |
Normal |
Abnormal |
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(419) Pure tone audiometry |
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(404) Head, face, neck, scalp |
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dB HL (hearing level) |
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(405) Buccal cavity, teeth |
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Hz |
Right ear |
Left ear |
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(406) Pharynx |
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250 |
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(407) Nasal passages and naso-pharynx |
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500 |
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(incl. anterior rhinoscopy) |
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1000 |
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(408) Vestibular system incl. Romberg test |
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2000 |
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(409) Speech/voice |
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3000 |
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(410) Sinuses |
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4000 |
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(411) Ext. acoustic meati, tympanic membranes |
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6000 |
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(412) Pneumatic otoscopy |
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8000 |
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(413) Impedance tympanometry including |
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Valsalva manoeuvre (initial only) |
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(420) Audiogram |
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o = Right – – – = Air |
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Additional testing (if indicated) |
Not performed |
Normal |
Abnormal |
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dB/HL |
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–10 |
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(414) Speech audiometry |
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0 |
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(415) Posterior rhinoscopy |
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10 |
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(416) EOG; spontaneous and positional nystagmus |
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20 |
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30 |
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(417) Differential caloric test or |
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40 |
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vestibular autorotation test |
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50 |
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(418) Mirror or fibre laryngoscopy |
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60 |
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70 |
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80 |
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(421) Otorhinolaryngology remarks and recommendation: |
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90 |
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100 |
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110 |
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120 |
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Hz 250 500 1000 2000 3000 4000 6000 8000 |
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(422) Examiner’s declaration: |
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I hereby certify that I/my AME group have personally examined the applicant named on this medical examination report and that this report with any attachment embodies my findings completely and correctly. |
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(423) Place and date: |
ORL examiner’s name and address: (block capitals) |
AME or specialist stamp with No: |
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AME or specialist signature: |
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E-mail: Telephone No: Telefax No: |
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INSTRUCTIONS FOR COMPLETION OF THE OTORHINOLARYNGOLOGY EXAMINATION REPORT FORM
Writing should be legible and in block capitals using a ball-point pen. Completion of this form by typing or printing is also acceptable. If more space is required to answer any question, a plain sheet of paper should be used, bearing the applicant’s name, the name and signature of the AME or otorhinolaryngology specialist performing the examination and the date of signing. The following numbered instructions apply to the numbered headings on the otorhinolaryngology examination report form.
Failure to complete the medical examination report form in full, as required, or to write legibly may result in non-acceptance of the application in total and may lead to withdrawal of any medical certificate issued. The making of false or misleading statements or the withholding of relevant information by an examiner may result in criminal prosecution, denial of an application or withdrawal of any medical certificate granted.
The AME or otorhinolaryngology specialist performing the examination should verify the identity of the applicant. The applicant should then be requested to complete the sections 1, 2, 3, 4, 5, 6, 7, 12 and 13 on the form and then sign and date the consent to release of medical information (section 401) with the examiner countersigning as witness.
402 EXAMINATION CATEGORY — Tick appropriate box.
Initial — Initial examination for class 1 or class 3; also initial examination for upgrading from class 2 to 1 or 3 (notate ‘upgrading’ in section 403).
Referral — NON-ROUTINE examination for assessment of an ORL symptom or finding.
403 OTORHINOLARYNGOLOGICAL HISTORY — Detail here any history of note or reasons for referral.
404–413 inclusive: CLINICAL EXAMINATION — These sections together cover the general clinical examination and each of the sections should be marked (with a tick) as normal or abnormal. Any abnormal findings or comments on findings should be entered in section 421.
414–418 inclusive: ADDITIONAL TESTING — These tests are only required to be performed if indicated by history or clinical findings and are not routinely required. For each test one of the boxes must be completed — if the test is not performed then tick that box — if the test has been performed then tick the appropriate box for a normal or abnormal result. All remarks and abnormal findings should be entered in section 421.
419 PURE TONE AUDIOMETRY — Complete figures for dB HL (hearing level) in each ear at all listed frequencies.
420 AUDIOGRAM — Complete audiogram from figures as listed in section 419.
421 OTORHINOLARYNGOLOGY REMARKS AND RECOMMENDATION — Enter here all remarks, abnormal findings and assessment results. Also enter any limitations recommended. If there is any doubt about findings or recommendations the examiner may contact the medical assessor for advice before finalising the report form.
422 OTORHINOLARYNGOLOGY EXAMINER’S DETAILS — The otorhinolaryngology examiner must sign the declaration, complete his/her name and address in block capitals, contact details and lastly stamp the report with his/her designated stamp incorporating his/her AME or specialist number.
423 PLACE AND DATE — Enter the place (town or city) and the date of examination. The date of examination is the date of the clinical examination and not the date of finalisation of form. If the ORL examination report is finalised on a different date, enter date of finalisation in section 421 as ‘Report finalised on...’.