Medical Evaluation for FAA 8500-8 Form

Notice and Instruction Page: Click on Image.
Application For: Class of Medical Certificate Applied For:
Last Name: Suffix:
First Name: Middle Name:
Social Security Number: Date of Birth:
- - / / MM / DD / YYYY
Home Phone: Business Phone:
Home Address: Business Address:
Occupation: Employer:
E-mail: Citizenship:
Height in Inches:   Weight in Pounds:   Color of Hair:   Color of Eyes:   Sex:  
Inches Pounds

Type of Airman Certificate(s) Held:

Airline Transport
ATC Specialist
Flight Engineer
Flight Navigator
Flight Instructor

Has Your FAA Airman Medical Certificate Ever Been
Denied, Suspended or Revoked?

If yes, give date: - MM - YYYY

Total Pilot Time (Civilian Only).

To Date: Hrs.
Past 6 Months: Hrs.

Date of Last FAA Medical Application.

No Prior Application.

Do You Currently Use Any Medication?
(Prescription or Non prescription)

If Yes, give:
1st Med.
2nd Med.
3rd Med.
4th Med.
If Medication is
not being taken
at this time then
Check "No"
If "Yes" is checked,
for a medication that is
being taken presently.
Please indicate with a
"Yes" or "No"
if the medication was
Previously Reported.

1st Med.

2nd Med.

3rd Med.

4th Med.

Yes No

Yes No

Yes No

Yes No

Do You Ever Use Near Vision Contact Lens(es) While Flying?


Medical History

HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING?  Answer "yes" for every condition you have ever had in your life.  In the EXPLANATION BOX below, you may note "PREVIOUSLY REPORTED, NO CHANGE" only if the explanation of the condition was reported on a prior application for an airman medical certificate and there has been no chance in your condition.

a. Yes No Frequent of severe headaches
b. Yes No Dizziness or fainting spell
c. Yes No Unconsciousness for any reason
d. Yes No Eye of vision trouble except glasses
e. Yes No Hay fever of allergy
f. Yes No Asthma of lung disease
g. Yes No Heart or vascular troubles
h. Yes No High or low blood pressure
i. Yes No Stomach, liver, or intestinal trouble
j. Yes No Kidney stone or blood in urine
k. Yes No Diabetes
l. Yes No Neurological disorders; epilepsy, seizures, strokes, paralysis, etc.
m. Yes No Mental disorders of any sort; depression, anxiety, etc.
n. Yes No Substance dependence of failed a drug test ever; or substance
abuse or use of illegal substance in the last 2 years.
o. Yes No Alcohol dependence or abuse
p. Yes No Suicide attempt
q. Yes No Motion sickness requiring medication
r. Yes No Military medical discharge
s. Yes No Medical rejection by military service
t. Yes No Rejection for life or health insurance
u. Yes No Admission to hospital
x. Yes No Other illness, disability, or surgery

Conviction and/or Administrative Action History

v. Yes No History of (1) any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug: or (2) history of any conviction(s) or administrative action(s) involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving privileges or which resulted in attendance at an educational or a rehabilitation program.
w. Yes No History of nontraffic conviction(s) (misdemeanors or felonies).

Explanations Box

Visits to Health Professional Within Last 3 Years

If Yes, give: Date
Type of Health Professional Consulted
Address Reason
Yes 1st

Yes 2nd

Yes 3rd

Yes 4th


Applicant's National Driver Register and Certifying Declarations:


Med-Fly Appointment Date:

/ / MM / DD / YYYY

If you have any concerns about your medical history.  SUBMIT this form to our Senior FAA Aviation Medical Examiner.


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