Form 8500-7 Report of Eye Evaluation

U.S. Department
of Transportation
Federal Aviation
Administration

INFORMATION FOR APPLICANT

REPORT OF EYE EVALUATION
Privacy Act Statement

Information requested on this form is solicited under the authority of Title 49 of the United States Code
(Transportation) sections 109(9), 40113(a), 44701-44703, and 44709 (1994) formerly codified in the
Federal Aviation Act of 1958, as amended, and Title 14 of the Code of Federal Regulations (CFR),
Part 67, Medical Standards and Certification. Submission of this information is mandatory and
incomplete submission will result in delay of consideration of or denial of application for an airman
medical certificate.
The purpose of this information is to determine whether an applicant meets Federal Aviation
Administration medical requirements to hold an airman medical certificate for further consideration
under 14 CFR 11.53 and 67.401. It is also used to depict airman population patterns and to update
certification procedures and medical standards. The information collected on this form becomes a
part of the Privacy Act System of Records DOT/FAA 847, General Air Transportation Records on
individuals, and is provided the protection outlined in the system's description as published in the
Federal Register.

Paperwork Reduction Act Statement: Applicants not meeting the distant visual acuity standards and
who desire an Authorization for Special Issuance of a Medical Certificate (Authorization) must submit
FAA Form 8500-7, Report of Eye Evaluation, for evaluation and determination by the FAA.
Submission of information is mandatory. The purpose of this information is to determine whether an
applicant meets FAA medical requirements to hold an airman medical certificate for further
consideration under Title 14 of the Code of Federal Regulations (CFR) 11.53 and 67.401. Any person
who is denied a medical certificate by an aviation medical examiner may appeal to the Federal Air
Surgeon under 14 CFR 67.409, Denial of medical certificate. This information is also used to depict
airman population patterns and to update certification procedures and medical standards.
If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden,
please direct your comments to the FAA at the following address: Federal Aviation Administration;
Aeromedical Certification Division, AAM-300; P.O. Box 26080; Oklahoma City, OK 73126-9922. The
public reporting burden for collection of information is estimated to average 15 minutes per response.
The agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The paperwork burden associated
with this form is currently approved under OMB number 2120-0034.

Tear off this cover sheet before submitting this form

FAA FORM 8500-7 (9-97) Supersedes Previous Edition

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Electronic Version (Adobe)

Form Approved OMB No. 2120-0034
U.S. DEPARTMENT OF TRANSPORTATION - FEDERAL AVIATION ADMINISTRATION

1. DATE

REPORT OF EYE EVALUATION
2A. NAME OF AIRMAN (Last, First, Middle)

2B. DATE OF BIRTH (Month, Day, Year)

2C. SEX (M or F)

3. ADDRESS OF AIRMAN (No. Street, City, State, Zip Code)

4. HISTORY -- Record pertinent history, past and present, concerning general health and visual problems.

5. HETEROPHORIA -- Record phorias, in prism diopters, with and without best lens correction in place.
(1) AT 20 FEET
EXO.

ESO.

EXO.

ESO.

HYPER.

EXO.

(2) AT 18 INCHES
ESO.
HYPER.

HYPER.

EXO.

ESO.

A. WITHOUT CORRECTION
(2) AT 18 INCHES

(1) AT 20 FEET

HYPER.

B. WITH CORRECTION (If any)
6. FUSION -- Estimate fusion ability and state methods used in examination . (Red lens, etc.)

7. PUPILS -- Statement of relative size and reaction of the pupils to accommodation and light, direct and con sensual.

8. VISUAL FIELDS -- Record results and type of test performed. (Attach field charts, if used).

9. OPHTHALMOSCOPIC -- Describe any variations from normal in either eye on funduscopic examination.

10. SLIT LAMP -- Record results of slit lamp examination of each eye where indicated.

11. INTRAOCULAR PRESSURE -- Record results and methods used.
O.D.

A. METHOD USED
12. VISUAL ACUITY (Use Snellen Equivalents)
TEST METHOD

UNCORRECTED
O.D.

A. DISTANT VISION

O.S.
LENSES USED

O.S.

O.U.

CORRECTED VISUAL ACUITY
O.D.

O.S.

O.U.

O.D.

O.S.

O.U.

O.D.

O.S.

O.U.

CONTACT LENSES
GLASSES

TEST METHOD
B. NEAR VISION
(16 INCHES)

UNCORRECTED
O.U.
O.D.
O.S.

CONTACT LENSES ONLY
GLASSES ONLY
GLASSES WITH CONTACTS

TEST METHOD
C. INTERMEDIATE
VISION
(32 INCHES)

UNCORRECTED
O.D.
O.U.
O.S.

CONTACT LENSES ONLY
GLASSES ONLY
GLASSES WITH CONTACTS

NOTE -- If contact lenses are used, corrected near visual acuity should be determined while these lenses are worn, indicate if the
contact lenses used (if any) were bifocal.
FAA FORM 8500-7 (9-97) Supersedes Previous Edition

Electronic Version (Adobe)

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.

NSN:0052-00-667-3002

13. PRESENT PRESCRIPTION (Sphere, cylinder, axis)
A. CONTACT LENSES
O.D.

B. GLASSES

O.S.

O. D.

O.S.

IF CONTACT LENSES ARE NOT USED, OMIT ITEMS 14-19.
14. TYPE OF LENSES (Corneal, scleral, lenticular, single-cut, bifocal, toric, non-rotating, special shape, etc.)

15. EXAMINATION FREQUENCY -- Indicate frequency of periodic follow up examination.

16. SYMPTOMS OR ABNORMAL CONDITIONS -- Note any lacrimation, photophobia, loss of lens, or evidence of corneal injury or edema, etc.,
requiring treatment and/or interruption of contact lens wearing. State results of slit lamp or biomicroscopic examination of cornea.

17. PROFESSIONAL EVALUATION -- Indicate your professional opinion and any other comment or additional observations.

18A. TYPED NAME AND ADDRESS OF EYE SPECIALIST

FAA FORM 8500-7 (9-97) Supersedes Previous Edition

18B. SIGNATURE OF EYE SPECIALIST

Electronic Version (Adobe)

NSN:0052-00-667-3002