Form 8500-8 Application for Airman Medical Certificate or Airman Med

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8610006268

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APPLICATION FOR AIRMAN MEDICAL CERTIFICATE OR
AIRMAN MEDICAL AND STUDENT PILOT CERTIFICATE

2006-552-757

8610006268

INSTRUCTIONS TO THE AVIATION MEDICAL EXAMINER
GENERAL INSTRUCTIONS FOR ISSUANCE OF ANY MEDICAL CERTIFICATE
UNITED STATES OF AMERICA

Department of Transportation
Federal Aviation Administration

FF-

Remove this page of instructions and attached certificate as well as the next page of
instructions and attached certificate before giving the applicant any part of this form.

MEDICAL CERTIFICATE
CLASS
AND STUDENT PILOT CERTIFICATE

INSTRUCTIONS FOR ISSUANCE OF THIS (Medical-Student Pilot) CERTIFICATE
1. Applicant must (a) be at least 16 years of age; (b) be able to read, speak, write, and
understand the English language; and (c) qualify at least for a third-class medical
certificate.

This certifies that (Full name and address):

2. Destroy these instructions and the following page’s Medical Certificate and
instructions which are printed on white paper.
Date of Birth

Height

Weight

Hair

Eyes

Sex

Limitations

has met the medical standards prescribed in part 67, Federal
Aviation Regulations, for this class of Medical Certificate.

4. When the application part is completed, destroy its instructions, remove the AME
Work Copy (middle sheet in set), and record your medical findings and actions on the
AME Work Copy. Type your findings and actions on the FAA/Original Copy. Give the
Applicant Copy to the applicant.
5. If the applicant qualifies for a certificate: (a) reassemble the FAA/Original Copy and
the AME Work Copy in their original order; (b) superimpose the Medical-Student Pilot
Certificate (yellow) on the FAA/Original Copy, upper left area; (c) complete the
certificate by typewriter; (d) sign the certificate in ink (both the AME and applicant must
sign); and (e) issue the signed certificate to the airman.

Date of Examination

Examiner

3. Give the applicant the instructions for completion of the medical history form and
the history forms. Have the applicant complete the history form in triplicate.

Examiner’s Designation No.

Signature

6. AME’s are required to use the electronic transmission capability of the Aeromedical
Certification System (AMCS) and must maintain the FAA/Original Copy in their files or,
if directed, forward it to the FAA in Oklahoma (see address below). If the FAA/Original
Copy is forwarded to the FAA, the AME Work Copy must be retained as the file copy.

Typed Name

AIRMAN’S SIGNATURE
FAA Form 8420-2 (3-99) Supersedes Previous Edition

7. BE SURE TO COMPLETE AND SIGN ITEM 64 ON THE FAA/ORIGINAL COPY.
forward the typed, completed FAA/Original Copy as follows and retain the AME Work
Copy as a file copy:
FAA AEROMEDICAL CERTIFICATION DIVISION, AAM-300
P.O. BOX 26080
OKLAHOMA CITY, OK 73126-5063
8. BE SURE TO COMPLETE AND SIGN ITEM 64 ON THE FAA/ORIGINAL COPY.

Rotorcraft

Glider

Airplane

Aircraft Category

CERTIFICATED INSTRUCTOR’S ENDORSEMENT FOR STUDENT PILOTS
I certify that the holder of this certificate has met the requirements of the regulations and is
competent for the following:
INSTRUCTOR’S CERT.
MAKE AND MODEL
INSTRUCTOR’S
DATE
OF AIRCRAFT
SIGNATURE
No.
Exp. Date

CONDITIONS OF ISSUE: This certificate shall be in the personal possession of the airman at all
times while exercising the privileges of his or her airman certificate. The issuance of a medical certificate
by an Aviation Medical Examiner may be reversed by the FAA within 60 days. Section 61.19 of Title 14
of the Code of Federal Regulations (14 CFR part 61) sets forth the duration of a student pilot certificate.
Unless otherwise limited, the duration of a medical certificate is set forth in § 61.23. The holder of this
certificate is governed by the provisions of § 61.53 relating to medical deficiency (14 CFR part 61).

A. To Solo The
Following Aircraft

B. To Make
Solo CrossCountry Flights

8610006268
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8610006268

Passenger-Carrying Prohibited

STUDENT PILOT CERTIFICATE

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8610006268

INSTRUCTIONS FOR ISSUANCE OF THIS MEDICAL CERTIFICATE
1. This certificate is for issuance to applicants other than those applying for a
Medical-Student Pilot Certificate.

UNITED STATES OF AMERICA

Department of Transportation
Federal Aviation Administration

MEDICAL CERTIFICATE

CLASS

2. Destroy these instructions and the attached Medical-Student Pilot Certificate and its
instructions which are printed on yellow paper.
3. Give the applicant the instructions for completion of the medical history form and the
history forms. Have the applicant complete the history form in triplicate.

This certifies that (Full name and address):

4. When the application part is completed, destroy its instructions, remove the AME
Work Copy (middle sheet in set), and record your medical findings and actions on the
AME Work Copy. Type your findings and actions on the FAA/Original Copy. Give the
Applicant Copy to the applicant.
Date of Birth

Height

Weight

Hair

Eyes

Sex

has met the medical standards prescribed in part 67, Federal
Aviation Regulations, for this class of Medical Certificate.

5. If the applicant qualifies for a certificate: (a) reassemble the FAA/Original Copy and
the AME Work Copy in their original order; (b) superimpose the Medical Certificate
(white) on the FAA/Original Copy, upper left area; (c) complete the certificate by
typewriter; (d) sign the certificate in ink (both the AME and applicant must sign); and
(e) issue the signed certificate to the airman.

Limitations

6. AME’s are required to use the electronic transmission capability of the Aeromedical
Certification System (AMCS) and must maintain the FAA/Original Copy in their files or,
if directed, forward it to the FAA in Oklahoma (see address below). If the FAA/Original
Copy is forwarded to the FAA, the AME Work Copy must be retained as the file copy.
7. BE SURE TO COMPLETE AND SIGN ITEM 64 ON THE FAA/ORIGINAL COPY.

Date of Examination

Examiner’s Designation No.

Examiner

8. BE SURE TO COMPLETE AND SIGN ITEM 64 ON THE FAA/ORIGINAL COPY.
Signature
Typed Name

AIRMAN’S SIGNATURE
FAA Form 8500-9 (3-99) Supersedes Previous Edition

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CONDITIONS OF ISSUE
The holder of this certificate must:
FIRST-CLASS
calendar
monthsat
forallthose
Have
it in his or her 6personal
possesion
times
operations
First-Class
while
exercising requiring
privilegesaof
an airmanMedical
certificate.
Certificate;
a.(14CFR
§ 61.3)12 calendar months for those
operationsthat requiring
only of
a Second-Class
Understand
the issuance
a medical certificate
Certificate;
24 or 36may
calendar
months,by
by Medical
an Aviation
Medical or
Examiner
be reversed
theas
FAA
setwithin
forth 60
in days.
§ 61.23, for those operations
(14CFR
§ 67.407)
requiring
only a Third-Class Medical Certificate.
Comply with validity standards specified for first-,
second-,
and third-class
certificates.
SECOND-CLASS
– medical
12 calendar
months for
(14CFR
61.23)
those § operations
requiring a Second-Class
Comply with any statement of functional, operational,
b. Medical Certificate; or 24 or 36 calendar months,
and/or time limitation issued as a condition of
as set forth in
§ 61.23, for those operations
certification.
requiring
only a Third-Class Medical Certificate.
(14CFR
§ 67.401)

(Note: A letter of authorization (or SODA) describing
24 or
calendar
months,
as at
anyTHIRD-CLASS
such limitations–must
be 36
kept
with this
certificate
forth
in §exercising
61.23, forthe
those
operations
all set
times
while
privileges
of anrequiring
airman
only a Third-Class Medical Certificate.
c.
certificate.)
Comply with the standards relating to prohibitions on
operation during medical deficiency.
PROHIBITIONS
ON61.53,
OPERATION
MEDICAL DEFICIENCY
(14CFR §§
63.19, DURING
and 65.49)
For International Operations Only: Some holders may
be affected by certain international medical standards.
Consult the U.S. Areronautical Information Publication
for U.S. differences with ICAO Annex 1 medical
standards.

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8610006268

INFORMATION FOR APPLICANT

Application For Airman Medical Certificate
or
Airman Medical and Student Pilot Certificate
Privacy Act Statement
The information on the attached FAA Form 8500-8, Application For Airman Medical Certificate or Airman Medical and
Student Pilot Certificate, is solicited under the authority of Title 49, United States Code (U.S.C.) (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, Code of Federal Regulations (CFR), part 67, Medical Standards and Certification.
Except for your Social Security Number (SSN), submission of this information is mandatory. Incomplete submission will
result in delay of further consideration or denial of your application for a medical certificate or medical and student pilot
certificate. Other than your SSN, the purpose of the information is to determine whether you meet Federal Aviation
Administration (FAA) medical requirements to hold a medical certificate or medical and student pilot certificate. The
information will also be used to provide data for the FAA’s automated medical certification system to depict airman
population patterns and to update certification procedures and medical standards. For air traffic control specialists
(ATCS) employed by the Federal Government, the information requested will be used as a basis for determining
medical eligibility for initial and continuing employment. The information becomes part of the FAA Privacy Act system
of records, DOT/FAA-847, General Air Transportation Records on Individuals. These records and information in these
records may be used (a) to provide basic airman certification and qualification information to the public upon request;
(b) to disclose information to the National Transportation Safety Board (NTSB) in connection with its investigation
responsibilities; (c) to provide information about airmen to Federal, state, and local law enforcement agencies when
engaged in the investigation and apprehension of drug law violators; (d) to provide information about enforcement
actions arising out of violations of the Federal Aviation Regulations to government agencies, the aviation industry, and
the public upon request; (e) to disclose information to another Federal agency, or to a court or an administrative
tribunal, when the Government or one of its agencies is a party to a judicial proceeding before the court or involved in
administrative proceedings before the tribunal; and (f) to disclose information to other Federal agencies for verification
of the accuracy or completeness of the information and; (g) to comply with the Prefatory Statement of General Routine
Uses for the Department of Transportation.
Submission of your SSN is not required by law and is voluntary. Refusal to furnish your SSN will not result in the denial
of any right, benefit, or privilege provided by law. Your SSN is solicited to assist in performing the agency’s functions
under 49 U.S.C. (Transportation). If supplied, it will be used by the FAA to associate all information in agency files
relating to you. If you refuse to supply your SSN, a substitute number or other identifier will be assigned, as required.
The written consent authorization of this form under No. 20, Applicant’s Declaration, permits the FAA to request
information, if any, pertaining to your driving record from the National Driver Register (NDR). The FAA will then match
such NDR information with the information you provide on the medical history part of the form. Since the NDR identifies
only probable matches, the FAA will verify the NDR information it receives with the state of record. You have the right
to request an NDR file check to determine if it contains any information and, if so, the accuracy of such information.
Notarized requests may be sent to: DOT/NHTSA/NTS-32, 400 7th Street, S.W., Washington, DC 20590-0001, and
must contain your complete name and date of birth. Other information about height, weight, and eye color will ensure
correct positive identification.

Paperwork Reduction Act Statement:

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject
to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction
Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for
this information collection is 2120-0034. Public reporting for this collection of information is estimated to be
approximately 2 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to
this collection of information are required to obtain a certificate by 14 CFR Parts 61 and 67. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden
to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer,
ASP-110.

Tear off this cover sheet before submitting this form.
FAA Form 8500-8 (3-99) Supersedes Previous Edition

NSN: 0052-00-670-6002

Instructions for Completion of the Application for Airman Medical Certificate
or Airman Medical and Student Pilot Certificate, FAA Form 8500-8
Applicant must fill in completely numbers 1 through 20 of the application using a ballpoint pen. Exert sufficient pressure to make legibl
e copies. The
following numbered instructions apply to the numbered headings on the application form that follows this page.
NOTICE – Intentional falsification may result in federal criminal prosecution. Intentional falsification may also result in suspension o r revocation of all
airman, ground instructor, and medical certificates and ratings held by you, as well as denial of this application for medical certification.

1. APPLICATION FOR – Check the appropriate box.
2. CLASS OF AIRMAN MEDICAL CERTIFICATE APPLIED
FOR – Check the appropriate box for the class of airman medical
certificate for which you are making application.
3. FULL NAME – If your name has changed for any reason, list
current name on the application and list any former name(s) in the
EXPLANATIONS box of number 18 on the application.
4. SOCIAL SECURITY NUMBER – The social security number
is optional; however, its use as a unique identifier does eliminate
mistakes.
5. ADDRESS – Give permanent mailing address and country.
Include your complete nine digit ZIP code if known. Provide your
current area code and telephone number.
6. DATE OF BIRTH – Specify month (MM), day (DD), and year
(YYYY) in numerals; e.g., 01/31/1950. Indicate citizenship; e.g.,
U.S.A.
7. COLOR OF HAIR – Specify as brown, black, blond, gray, or red.
If bald, so state. Do not abbreviate.
8. COLOR OF EYES – Specify actual eye color as brown, black,
blue, hazel, gray, or green. Do not abbreviate.
9. SEX – Indicate male or female.
10. TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD – Check
applicable block(s). If “Other” is checked, provide name of certificate.
11. OCCUPATION – Indicate major employment. “Pilot” will be used
only for those gaining their livelihood by flying.
12. EMPLOYER – Provide your employer’s full name. If
self-employed, so state.
13. HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER
BEEN DENIED, SUSPENDED, OR REVOKED – If “yes” is checked,
give month and year of action in numerals.
14. TOTAL PILOT TIME TO DATE – Give total number of civilian
flight hours. Indicate whether logged or estimated. Abbreviate as
Log. or Est.
15. TOTAL PILOT TIME PAST 6 MONTHS – Give number of civilian
flight hours in the 6-month period immediately preceding date of this
application. Indicate whether logged or estimated. Abbreviate as
Log. or Est.
16. MONTH AND YEAR OF LAST FAA MEDICAL EXAMINATION
– Give month and year in numerals. If none, so state.
17.a. DO YOU CURRENTLY USE ANY MEDICATION (Prescription
or Nonprescription) – Check “yes” or “no.” If “yes” is checked, give
name of medication(s) and indicate if the medication was listed in a
previous FAA medical examination. See NOTE below.
17.b. Indicate whether you use near vision contact lens(es) while
flying.
18. MEDICAL HISTORY – Each item under this heading must be
checked either “yes” or “no.” You must answer “yes” for every
condition you have ever been diagnosed with, had, or presently have
and describe the condition and approximate date in the
EXPLANATIONS block.
If information has been reported on a previous application for airman
medical certificate and there has been no change in your condition,
you may note “PREVIOUSLY REPORTED, NO CHANGE” in the
EXPLANATIONS box, but you must still check “yes” to the condition.
Do not report occasional common illnesses such as colds or sore
throats.

“Substance dependence” is defined by any of the following:
increased tolerance; withdrawal symptoms; impaired control of use;
or continued use despite damage to health or impairment of social,
personal, or occupational functioning. “Substance abuse” includes
the following: use of an illegal substance; use of a substance or
substances in situations in which such use is physically hazardous;
or misuse of a substance when such misuse has impaired health or
social or occupational functioning. “Substances” include alcohol,
PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and
other psychoactive chemicals.

Arrest, Conviction
and/or Administrative
Action- Letter
History
Letter
Conviction
and/or Administrative
Action History
(v)- of
this (v)
of this subheading
askshave
if youever
have
ever(1)
been:
(1) arrested
and/or
subheading
asks if you
been:
convicted
(which may
convicted
(which
mayor include
fine, or forfeiting
bond or
include
paying
a fine,
forfeitingpaying
bond ora collateral)
of an offense
collateral)driving
of an offense
involving by,
driving
while
intoxicated
by, while
involving
while intoxicated
while
impaired
by, or while
under
theby,
influence
alcohol
a drug; orof(2)
convicted
or subject
impaired
or whileofunder
theorinfluence
alcohol
or a drug;
or (2)
to
an administrative
action
by atostate
or other jurisdiction
arrested,
convicted or
subject
an administrative
actionfor
byan
a state
offense
forjurisdiction
which your for
license
was denied,
suspended,
or
or other
an offense
for which
your cancelled,
license was
revoked
or which resulted
in attendance
at anor
educational
or
denied, suspended,
cancelled,
or revoked
which resulted
in
rehabilitation
Individualortraffic
convictions
are not
attendance atprogram.
an educational
rehabilitation
program.
Individual
traffic convictions are ___
not required to be reported if theyrequired
did
not
_____
to
be reported
if they
notsuspension,
involve: alcohol
or a drug;
suspension,
involve:
alcohol
or a did
drug;
revocation,
cancellation,
or
revocation,
cancellation,
or denial
of driving privileges;
or
denial of driving
privileges;
or attendance
at an educational
or
attendance
educational
or rehabilitation
If
“yes”
rehabilitationat an
program.
If “yes”
is checked, program.
a description
of theis
checked,
a
description
of
the
conviction(s)
and/or
administrative
conviction(s) and/or administrative action(s) must be given in the
action(s) must be given in the EXPLANATIONS box. The description
EXPLANATIONS box. The description must include: (1) the alcohol
must include: (1) the alcohol or drug offense for which you were
or drug offense for which you were convicted or the type of
convicted or the type of administrative action involved (e.g.,
administrative
action
involved
attendance
an alcohol
attendance
at an
alcohol
treatment(e.g.,
program
in lieu ofatconviction;
treatment
program
in lieu ofcancellation,
conviction; license
denial,for
suspension,
license
denial,
suspension,
or revocation
refusal to
cancellation,
or revocation
refusal
to be tested;
educational
safe
be
tested; educational
safefor
driving
program
for multiple
speeding
driving program
convictions;
etc.); (2) the
convictions;
etc.);for
(2) multiple
the namespeeding
of the state
or other jurisdiction
name of the
or other
jurisdiction
involved;
and
(3) the date of
involved;
andstate
(3) the
date of
the conviction
and/or
administrative
the conviction
and/or
administrative
action.
Thedriving
FAA licensing
may check
action.
The FAA
may check
state motor
vehicle
state motor
vehicle
driving licensing
to verify asks
your
records
to verify
your responses.
Letter (w)records
of this subheading
Letterhad
(w)any
of this
subheading
if you have
ever
had
ifresponses.
you have ever
other
(nontraffic)asks
convictions
(e.g.,
assault,
any other
(nontraffic)
convictions
battery,
public
battery,
public
intoxication,
robbery, (e.g.,
etc.). Ifassault,
so, name
the charge
for
intoxication,
robbery,
etc.).and
If so,
charge for
which you
which
you were
convicted
thename
date ofthe
conviction
in the
EXPLANATIONS
box.
NOTE
below. in the EXPLANATIONS
were convicted and
theSee
date
of conviction
box. See NOTE below.
19. VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS
– List all visits in the last 3 years to a physician, physician assistant,
nurse practitioner, psychologist, clinical social worker, or substance
abuse specialist for treatment, examination, or medical/mental
evaluation. List visits for counseling only if related to a personal
substance abuse or psychiatric condition. Give date, name,
address, and type of health professional consulted and briefly state
reason for consultation. Multiple visits to one health professional for
the same condition may be aggregated on one line. Routine dental,
eye, and FAA periodic medical examinations and consultations with
your employer-sponsored employee assistance program (EAP) may
be excluded unless the consultations were for your substance abuse
or unless the consultations resulted in referral for psychiatric
evaluation or treatment. See NOTE below.
20. APPLICANT’S DECLARATION – Two declarations are
contained under this heading. The first authorizes the National
Driver Register to release adverse driver history information, if any,
about the applicant to the FAA. The second certifies the
completeness and truthfulness of the applicant’s responses on the
medical application. The declaration section must be signed and
dated by the applicant after the applicant has read it.

NOTE: If more space is required to respond to “yes” answers for numbers 17, 18, or 19, use a plain sheet of paper
bearing the information, your signature, and the date signed.

Applicant — Please Tear Off This Sheet After Completing The Application Form.
FAA Form 8500-8 (3-99) Supersedes Previous Edition

NSN: 0052-00-670-6002

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Applicant Must Complete ALL 20 Items (Except For Shaded Areas) PLEASE PRINT
Copy of FAA Form 8500-9
(Medical Certificate) or FAA
Form 8420-2 (Medical/Student
Pilot Certificate) issued.

FF-

MEDICAL CERTIFICATE
CLASS
AND STUDENT PILOT CERTIFICATE
This certifies that (Full name and address):

1. Application For:
Airman Medical
Certificate
3. Last Name

Form Approved OMB NO. 2120-0034

2. Class of Medical Certificate Applied For:
1st
2nd
3rd

Airman Medical and
Student Pilot Certificate
First Name

Middle Name

4. Social Security Number
Telephone Number (

5. Address

)

—

Number / Street
City

Date of Birth

Height

Weight

Hair

Eyes

Sex

State / Country

6. Date of Birth

7. Color of Hair
M M

Limitations

has met the medical standards prescribed in part 67, Federal
Aviation Regulations, for this class of Medical Certificate.

Zip Code

/

D D

/

8. Color of Eyes

Citizenship
10. Type of Airman Certificate(s) You Hold:

None
Airline Transport
Commercial

ATC Specialist
Flight Engineer
Flight Navigator

Flight Instructor
Private
Student

11. Occupation

Recreational
Other

12. Employer

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

Date of Examination

Examiner’s Designation No.

If yes, give date

No

Total Pilot Time (Civilian Only)
14. To Date
15. Past 6 Months

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application

Y
P
O
M M / D D / Y Y Y Y

Examiner

9. Sex

Y Y Y Y

Signature

No Prior
Application

17.a. Do You Currently Use Any Medication (Prescription or Nonprescription)?
Yes (If yes, below list medication(s) used and check appropriate box).
Previously Reported
No

Typed Name

AIRMAN’S SIGNATURE

C
L
A

Yes

No

(If more space is required, see 17. a. on the instruction sheet).

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

Yes

No

18. Medical History - HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING?
Answer “yes” or “no”
for every condition listed below. In the EXPLANATIONS box below, you may note “PREVIOUSLY REPORTED, NO CHANGE” only if the explanation of the condition was
reported on a previous application for an airman medical certificate and there has been no change in your condition.
See Instructions Page
Yes No
Condition
Yes No
Condition
Yes No
Condition
Yes No
Condition
Mental disorders of any sort;
a.
Frequent or severe headaches
g.
Heart or vascular trouble
m.
r.
Military
medical
discharge
depression, anxiety, etc.
Substance dependence or failed
n.
Dizziness or fainting spell
High or low blood pressure
Medical rejection by military service
b.
h.
s.
a drug test ever; or substance
abuse or use of illegal substance
Rejection for life or health insurance
Unconsciousness for any reason
Stomach, liver, or intestinal trouble
c.
i.
t.
in the last 2 years.

O
/
A
A

N
I
G
I
R

d.

Eye or vision trouble except glasses j.

Kidney stone or blood in urine

o.

Alcohol dependence or abuse

u.

Admission to hospital

e.

Hay fever or allergy

k.

Diabetes

p.

Suicide attempt

x.

Other illness, disability, or surgery

l.

Neurological disorders; epilepsy,
seizures, stroke, paralysis, etc.

q.

Motion sickness requiring medication

y.

Medical disability benefits

f.

Asthma or lung disease

F

Arrest, Conviction,
Administrative
Action
History —
--- See
Page
Conviction
and/orand/or
Administrative
Action
History
SeeInstructions
Instructions
Page
Yes No

History of (1) any arrest, and/or 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 arrest, and/or 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.
Explanations: See Instructions Page

v.

— NOTICE —

History of nontraffic
conviction(s)
(misdemeanors or felonies).
FOR FAA USE
Review Action Codes

19. Visits to Health Professional Within Last 3 Years.
Yes (Explain Below)
Date
Name, Address, and Type of Health Professional Consulted

Whoever in any matter within the
jurisdiction of any department or
agency of the United States
knowingly and willingly falsifies,
conceals or covers up by any trick,
scheme, or device a material fact,
or who makes any false, fictitious
or fraudulent statements or
representations, or entry, may be
fined up to $250,000 or imprisoned
not more than 5 years, or both.
(18 U.S. Code Secs. 1001; 3571).

Yes No
w.

No

See Instructions Page
Reason

20. Applicant’s National Driver Register and Certifying Declarations
I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to t he FAA
information pertaining to my driving record. This consent constitutes authorization for a single access to the information cont ained in the NDR
to verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if any, available
for my review and written comment. Authority: 23 U.S Code 401, Note.
NOTE: ALL persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an
application for Medical Certificate or Medical Certificate and Student Pilot Certificate.
I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of m
and I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and un
Privacy Act statement that accompanies this form.
Signature of Applicant

FAA Form 8500-8 (3-99) Supersedes Previous Edition

y knowledge,
derstand the

Date
M M / D D / Y Y Y Y

NSN: 0052-00-670-6002

B-4A

8610006268

B-4A

8610006268

NOTE: FAA/Original Copy of the Report of Medical Examination Must be TYPED.
REPORT OF MEDICAL EXAMINATION
21. Height (inches)

22. Weight (pounds)

23. Statement of Demonstrated Ability (SODA)
YES
NO
Defect Noted:

24. SODA Serial Number

Normal Abnormal CHECK EACH ITEM IN APPROPRIATE COLUMN
Normal Abnormal
CHECK EACH ITEM IN APPROPRIATE COLUMN
25. Head, face, neck, and scalp
37. Vascular system (Pulse, amplitude and character; arms, legs, others)
26. Nose
38. Abdomen and viscera (Including hernia)
27. Sinuses
39. Anus (Not including digital examination)
28. Mouth and throat
40. Skin
29. Ears, general (Internal and external canals; Hearing under item 49)
41. G-U system (Not including pelvic examination)
30. Ear Drums (Perforation)
42. Upper and lower extremities (Strength and range of motion)
31. Eyes, general (Vision under items 50 to 54)
43. Spine, other musculoskeletal
44. Identifying body marks, scars, tattoos (Size & location)
32. Ophthalmoscopic
33. Pupils (Equality and reaction)
45. Lymphatics
reflexes, equilibrium, senses, cranial nerves,
46. Neurologic (Tendon
34. Ocular motility (Associated parallel movement, nystagmus)
coordination, etc.)
47. Psychiatric (Appearance, behavior, mood, communication, and memory)
35. Lungs and chest (Not including breast examination)
36. Heart (Precordial activity, rhythm, sounds, and murmurs)
48. General systemic
NOTES: Describe every abnormality in detail. Enter applicable item number before each comment. Use additional sheets if necessary and attach to this form.

49. Hearing
Conversational
Voice Test at 6 Feet

Pass

Record Audiometric Speech
Discrimination Score Below

Right Ear
Threshold in
decibels

Fail

50. Distant Vision
Right 20/
Left 20/
Both 20/

500

Audiometer

1000

2000

Corrected to
Corrected to
Corrected to

20/
20/
20/

Left Ear
3000

51.a. Near Vision
Corrected to
Corrected to
Corrected to

53. Field of Vision

20/
20/
20/

Right 20/
Left 20/
Both 20/

54. Heterophoria 20’

Normal
Abnormal
55. Blood Pressure
Systolic
Diastolic

56. Pulse
(Resting)

500

1000

2000

51.b. Intermediate Vision - 32 Inches

(in prism diopters)

Esophoria

57. Urinalysis
give
results)
Urine Test (if(ifabnormal,
abnormal,
give
results)
Normal

(Sitting,
mm of Mercury)

4000

Abnormal

Right 20/
Left 20/
Both 20/

Corrected to
Corrected to
Corrected to

Exophoria

Albumin

3000

4000

52. Color Vision

20/
20/
20/

Pass
Fail

Right Hyperphoria

Left Hyperphoria

58. ECG (Date)
M M D D Y YYY

Sugar

59. Other Tests Given

60. Comments on History and Findings: AME shall comment on all “YES” answers in the Medical History section and for
abnormal findings of the examination. (Attach all consultation reports, ECGs, X-rays, etc. to this report before mailing.)

FOR FAA USE
Pathology Codes:

Coded By:
Clerical Reject
Significant Medical History

YES

Abnormal Physical Findings

NO

YES

NO

Medical Certificate
Medical & Student Pilot Certificate
62. Has Been Issued —
No Certificate Issued — Deferred for Further Evaluation
Has Been Denied — Letter of Denial Issued (Copy Attached)

61. Applicant’s Name

63. Disqualifying Defects (List by item number)
64. Medical Examiner’s Declaration — I hereby certify that I have personally reviewed the medical history and personally examined the applicant named on
this medical examination report. This report with any attachment embodies my findings completely and correctly.
Date of Examination
Aviation Medical Examiner’s Name
Aviation Medical Examiner’s Signature

M M

D D Y YYY

Street Address
AME Serial Number
City

FAA Form 8500-8 (3-99) Supersedes Previous Edition

State

Zip Code

AME Telephone (

)
NSN: 0052-00-670-6002

5A

8610006268

5A

8610006268

Applicant Must Complete ALL 20 Items (Except For Shaded Areas) PLEASE PRINT
Copy of FAA Form 8500-9
(Medical Certificate) or FAA
Form 8420-2 (Medical/Student
Pilot Certificate) issued.

FF-

MEDICAL CERTIFICATE
CLASS
AND STUDENT PILOT CERTIFICATE
This certifies that (Full name and address):

1. Application For:
Airman Medical
Certificate
3. Last Name

Form Approved OMB NO. 2120-0034

2. Class of Medical Certificate Applied For:
1st
2nd
3rd

Airman Medical and
Student Pilot Certificate
First Name

Middle Name

4. Social Security Number
Telephone Number (

5. Address

)

—

Number / Street
City

Date of Birth

Height

Weight

Hair

Eyes

Sex

State / Country

6. Date of Birth

7. Color of Hair
M M

Limitations

has met the medical standards prescribed in part 67, Federal
Aviation Regulations, for this class of Medical Certificate.

Zip Code

/

D D

/

8. Color of Eyes

Citizenship
10. Type of Airman Certificate(s) You Hold:

None
Airline Transport
Commercial

ATC Specialist
Flight Engineer
Flight Navigator

Flight Instructor
Private
Student

11. Occupation

Recreational
Other

12. Employer

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

Date of Examination

Examiner’s Designation No.

If yes, give date

No

Total Pilot Time (Civilian Only)
14. To Date
15. Past 6 Months

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application
No Prior
Application

M M / D D / Y Y Y Y

Examiner

9. Sex

Y Y Y Y

Signature

17.a. Do You Currently Use Any Medication (Prescription or Nonprescription)?
Yes (If yes, below list medication(s) used and check appropriate box).
Previously Reported
No

Typed Name

Yes

Y
P
O

AIRMAN’S SIGNATURE

No

(If more space is required, see 17. a. on the instruction sheet).

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

C
K
R

Yes

No

18. Medical History - HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING?
Answer “yes” or “no”
for every condition listed below. In the EXPLANATIONS box below, you may note “PREVIOUSLY REPORTED, NO CHANGE” only if the explanation of the condition was
reported on a previous application for an airman medical certificate and there has been no change in your condition.
See Instructions Page
Yes No
Condition
Yes No
Condition
Yes No
Condition
Yes No
Condition
Mental disorders of any sort;
a.
Frequent or severe headaches
g.
Heart or vascular trouble
m.
r.
Military
medical
discharge
depression, anxiety, etc.
Substance dependence or failed
n.
Dizziness or fainting spell
High or low blood pressure
Medical rejection by military service
b.
h.
s.
a drug test ever; or substance
abuse or use of illegal substance
Rejection for life or health insurance
Unconsciousness for any reason
Stomach, liver, or intestinal trouble
c.
i.
t.
in the last 2 years.
d.

Eye or vision trouble except glasses j.

e.

Hay fever or allergy

f.

O
W
E

k.

Asthma or lung disease

AM
l.

Kidney stone or blood in urine
Diabetes

Neurological disorders; epilepsy,
seizures, stroke, paralysis, etc.

o.

Alcohol dependence or abuse

u.

Admission to hospital

p.

Suicide attempt

x.

Other illness, disability, or surgery

q.

Motion sickness requiring medication y.

Medical disability benefits

Arrest, Conviction,
and/or
Administrative
Action
History —
--- See
Page
Conviction
and/or
Administrative
Action
History
SeeInstructions
Instructions
Page
Yes No

History of (1) any arrest, and/or 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 arrest, and/or 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.
Explanations: See Instructions Page

v.

19. Visits to Health Professional Within Last 3 Years.
Yes (Explain Below)
Date
Name, Address, and Type of Health Professional Consulted

— NOTICE —

Whoever in any matter within the
jurisdiction of any department or
agency of the United States
knowingly and willingly falsifies,
conceals or covers up by any trick,
scheme, or device a material fact,
or who makes any false, fictitious
or fraudulent statements or
representations, or entry, may be
fined up to $250,000 or imprisoned
not more than 5 years, or both.
(18 U.S. Code Secs. 1001; 3571).

Yes No
w.

History of nontraffic
conviction(s)
(misdemeanors or felonies).
FOR FAA USE
Review Action Codes

No

See Instructions Page
Reason

20. Applicant’s National Driver Register and Certifying Declarations
I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to t he FAA
information pertaining to my driving record. This consent constitutes authorization for a single access to the information cont ained in the NDR
to verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if any, available
for my review and written comment. Authority: 23 U.S Code 401, Note.
NOTE: ALL persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an
application for Medical Certificate or Medical Certificate and Student Pilot Certificate.
I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of m
and I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and un
Privacy Act statement that accompanies this form.
Signature of Applicant

FAA Form 8500-8 (3-99) Supersedes Previous Edition

y knowledge,
derstand the

Date
M M / D D / Y Y Y Y

NSN: 0052-00-670-6002

6A

8610006268

6A

8610006268

Applicant Must Complete ALL 20 Items (Except For Shaded Areas) PLEASE PRINT
Copy of FAA Form 8500-9
(Medical Certificate) or FAA
Form 8420-2 (Medical/Student
Pilot Certificate) issued.

FF-

MEDICAL CERTIFICATE
CLASS
AND STUDENT PILOT CERTIFICATE
This certifies that (Full name and address):

1. Application For:
Airman Medical
Certificate
3. Last Name

Form Approved OMB NO. 2120-0034

2. Class of Medical Certificate Applied For:
1st
2nd
3rd

Airman Medical and
Student Pilot Certificate
First Name

Middle Name

4. Social Security Number
Telephone Number (

5. Address

)

—

Number / Street
City

Date of Birth

Height

Weight

Hair

Eyes

Sex

State / Country

6. Date of Birth

7. Color of Hair
M M

Limitations

has met the medical standards prescribed in part 67, Federal
Aviation Regulations, for this class of Medical Certificate.

Zip Code

/

D D

/

8. Color of Eyes

Citizenship
10. Type of Airman Certificate(s) You Hold:

None
Airline Transport
Commercial

ATC Specialist
Flight Engineer
Flight Navigator

Flight Instructor
Private
Student

11. Occupation

Recreational
Other

12. Employer

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

Date of Examination

Examiner’s Designation No.

If yes, give date

No

Total Pilot Time (Civilian Only)
14. To Date
15. Past 6 Months

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application
No Prior
Application

M M / D D / Y Y Y Y

Examiner

9. Sex

Y Y Y Y

Signature

Y
P
O
C

17.a. Do You Currently Use Any Medication (Prescription or Nonprescription)?
Yes (If yes, below list medication(s) used and check appropriate box).
Previously Reported
No

Typed Name

AIRMAN’S SIGNATURE

Yes

No

(If more space is required, see 17. a. on the instruction sheet).

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

Yes

No

18. Medical History - HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING?
Answer “yes” or “no”
for every condition listed below. In the EXPLANATIONS box below, you may note “PREVIOUSLY REPORTED, NO CHANGE” only if the explanation of the condition was
reported on a previous application for an airman medical certificate and there has been no change in your condition.
See Instructions Page
Yes No
Condition
Yes No
Condition
Yes No
Condition
Yes No
Condition
Mental disorders of any sort;
a.
Frequent or severe headaches
g.
Heart or vascular trouble
m.
r.
Military
medical
discharge
depression, anxiety, etc.
Substance dependence or failed
n.
Dizziness or fainting spell
High or low blood pressure
Medical rejection by military service
b.
h.
s.
a drug test ever; or substance
abuse or use of illegal substance
Rejection for life or health insurance
Unconsciousness for any reason
Stomach, liver, or intestinal trouble
c.
i.
t.
in the last 2 years.

T
N
A

C
I
PL

d.

Eye or vision trouble except glasses j.

Kidney stone or blood in urine

o.

Alcohol dependence or abuse

u.

Admission to hospital

e.

Hay fever or allergy

Diabetes

p.

Suicide attempt

x.

Other illness, disability, or surgery

q.

Motion sickness requiring medication

y.

Medical disability benefits

f.

k.

P
A

Asthma or lung disease

l.

Neurological disorders; epilepsy,
seizures, stroke, paralysis, etc.

Conviction
and/or
Administrative
Action
SeeInstructions
Instructions
Page
Arrest, Conviction,
and/or
Administrative
ActionHistory
History —
--- See
Page
Yes No

History of any arrest, and/or conviction(s) involving driving while intoxicated by, while impaired by, or while
v.
under the influence of alcohol or a drug; or (2) history of any arrest, and/or 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.
Explanations: See Instructions Page

19. Visits to Health Professional Within Last 3 Years.
Yes (Explain Below)
Date
Name, Address, and Type of Health Professional Consulted

— NOTICE —

Whoever in any matter within the
jurisdiction of any department or
agency of the United States
knowingly and willingly falsifies,
conceals or covers up by any trick,
scheme, or device a material fact,
or who makes any false, fictitious
or fraudulent statements or
representations, or entry, may be
fined up to $250,000 or imprisoned
not more than 5 years, or both.
(18 U.S. Code Secs. 1001; 3571).

Yes No
w.

History of nontraffic
conviction(s)
(misdemeanors or felonies).
FOR FAA USE
Review Action Codes

No

See Instructions Page
Reason

20. Applicant’s National Driver Register and Certifying Declarations
I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to t he FAA
information pertaining to my driving record. This consent constitutes authorization for a single access to the information cont ained in the NDR
to verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if any, available
for my review and written comment. Authority: 23 U.S Code 401, Note.
NOTE: ALL persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an
application for Medical Certificate or Medical Certificate and Student Pilot Certificate.
I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of m
and I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and un
Privacy Act statement that accompanies this form.
Signature of Applicant

FAA Form 8500-8 (3-99) Supersedes Previous Edition

y knowledge,
derstand the

Date
M M / D D / Y Y Y Y

NSN: 0052-00-670-6002