Form 8700-2 BasicMed Comprehensive Medical Examination Checklist

Comprehensive Medical Examination Checklist

SECTION 1 – Instructions to the Individual and State-Licensed Physician

This checklist is to be used by individuals seeking to operate certain small aircraft in accordance with Chapter 14 of Code of Federal Regulations (14 CFR), Section 61.113(i). This rule (BasicMed) allows pilots to use this checklist, and other requirements, in lieu of holding third-class FAA Airman Medical Certificate. Under BasicMed, an individual may only act as pilot-in-command (PIC) of an aircraft that is authorized to carry not more than 6 occupants, and that has a maximum certificated takeoff weight of not more than 6,000 pounds.

1. The individual must complete SECTION 2 of this checklist and provide the checklist in its entirety (including the completed SECTION 2) to the state-licensed physician performing the medical examination.

2. The state-licensed physician must perform a comprehensive medical examination addressing all items in SECTION 3 of this checklist. The physician completes the “Physician’s Signature and Declaration” if the physician determines that he/she is not aware of any medical condition that, as presently treated, could interfere with the individual’s ability to safely operate an aircraft.

3. The completed checklist shall be retained in the individual's logbook (either as a hard copy or electronically) and made available on request.

4. In order to act as PIC under BasicMed, an individual must receive a comprehensive medical examination by a state-licensed physician during the previous 48 months in accordance with 14 CFR 61.23(c)(3)(i).

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)

Paperwork Reduction Act Statement:

The information collected on this form is necessary to determine applicant eligibility for operating under BasicMed. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. The OMB control number associated with this collection of information is 2120-####. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Avenue SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20.

SECTION 2 – Information to be completed by the Airman

If you seek to use BasicMed, you may only use this checklist to comply with 14 CFR 61.113(i) if you:

• Hold or have held a valid first-, second-, or third-class medical certificate issued by the FAA at any time after July 14, 2006; and

• The most recent medical certificate held (including an authorization for a special issuance certificate) must have not been denied, suspended, revoked, or withdrawn.

INSTRUCTIONS: After completing all mandatory fields in SECTION 2, provide both SECTION 2 and SECTION 3 to the state-licensed physician who will perform your medical examination.

1. OMITTED: Leave blank

2. OMITTED: Leave blank

3. FULL NAME: List current name. List any former name(s) in the “additional comments or explanation” box found in #18 of the checklist form.

4. SOCIAL SECURITY NUMBER: Entry is optional.

5. ADDRESS: Enter permanent mailing address and country of residence. Include the nine digit ZIP code, if known. (e.g., 20003-3230). Provide your current telephone number, including area code.

6. DATE OF BIRTH: List month, day, and year (e.g., 01/31/1960). COUNTRY OF CITIZENSHIP: Enter citizenship (e.g., USA).

7. COLOR OF HAIR: Specify as black, blond, brown, gray, red, or bald.

8. COLOR OF EYES: Specify actual (not contact lenses) eye color as black, blue, brown, green, gray, or hazel.

9. SEX: Indicate male or female.

10. TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD: Select the checkboxes that apply. If "Other" is selected, write in the name of the type of certificate.

11. OCCUPATION: Enter major employment. Entry is optional.

12. EMPLOYER: Enter your employer. Entry is optional.

13. HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, REVOKED, OR WITHDRAWN: Select "Yes" or "No." If "Yes” is selected, list the month and year (e.g., 01/1999) of the action.

14. OMITTED: Leave blank

15. OMITTED: Leave blank

16. DATE OF LAST FAA MEDICAL EXAMINATION: Enter month and year. If you have no prior application, you cannot use BasicMed.

17. a. DO YOU CURRENTLY USE ANY MEDICATION (prescription or non-prescription): Select "Yes" or "No." If "Yes" is selected, enter the name of the medication(s), dosage, and frequency used.

b. DO YOU EVER USE NEAR VISION CONTACT LENSES WHILE FLYING: Select “Yes” or “No.” Example: If you have one contact that is calibrated to give you near vision and one that is calibrated to give you distant vision, check “Yes.” If you wear a contact in only one eye to correct for near vision, check “Yes.”

18. a – x. MEDICAL HISTORY: Select “Yes” or “No” for each item listed. For every condition you have ever been diagnosed with, had, or presently have, you must answer "Yes." Give the approximate date, description of the condition, its severity, treatment, and any medication(s) you used or continue to use for treatment. You must give an explanation for each item marked “Yes” in the “additional comments or explanation” box.

• Do not report common, occasional illnesses such as colds or sore throats.

• “Substances” include alcohol, PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and other psychoactive chemicals.

• "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" is defined as 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.

18. v. CONVICTION, AND/OR ADMINISTRATIVE ACTION HISTORY:

(1) Have you ever been convicted (which may include paying a fine or forfeiting bond or collateral) of an offense involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug;

or

(2) Have you ever been convicted, and/or subject to an administrative action by a state or other jurisdiction for an offense for which your license was denied, suspended, cancelled, or revoked or which resulted in attendance at an educational or rehabilitation program? Individual traffic convictions are not required to be reported if they did not involve alcohol/drugs, suspension, revocation, cancellation, or denial of driving privileges, or attendance at an educational or rehabilitation program. If "Yes" is checked, you must give a description of the conviction(s) and/or administrative action(s) in the “additional comments or explanation” box. The description must include:

• The alcohol or drug offense for which you were arrested and/or convicted or the type of administrative action involved (e.g., attendance at an alcohol treatment program in lieu of conviction; license denial, suspension, cancellation, or revocation for refusal to be tested; educational safe driving program for multiple speeding convictions, etc.);

• The name of the state or other jurisdiction involved; and

• The date of the conviction(s) and/or administrative action(s). The FAA may check state motor vehicle driving licensing records to verify your responses.

18. w. HISTORY OF NON-TRAFFIC CONVICTIONS(S) (MISDEANORS OR FELONIES): Have you ever had any other (non-traffic) convictions (e.g., assault, battery, public intoxication, robbery, etc.)? If so, name the charge for which you were convicted and the date of conviction in the “additional comments or explanation" box.

18. 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 it was related to a personal substance abuse or psychiatric condition.

Enter the date of visit as month and year (e.g., 01/1990), name, address, and type of health professional consulted and briefly state reason for consultation. Repeat this process to add all relevant visits to medical professionals in the past 3 years. Multiple visits to one health professional for the same condition may be grouped together on one line. You do not need to report:

• Occasional common illnesses such as colds or sore throats that resolved;

• Routine dental, eye, and FAA periodic medical examinations; or

• Consultations with your employer-sponsored employee assistance program (EAP) unless the consultations were for substance abuse or unless the consultations resulted in referral for psychiatric evaluation or treatment.

NOTE: After completing SECTION 2, carefully review and read the affirmation statements under the “Airman’s Signature and Declarations.” If you agree with the statements, sign and date the document. Once you have completed, signed, and dated SECTION 2, you must provide ALL sections (SECTION 1-3) of this checklist to the state-licensed physician who will perform and complete the comprehensive medical examination, as required by Section 2307(a)(7) of FESSA.

BASICMED SECTION 2: INDIVIDUAL INFORMATION (To be completed by the airman)

1-2

Omitted

3

Name: Last First Middle

4

SS # (optional)

5

Address/street Telephone ( ) _______ -_____________

City State/Country Zip Code:

6.

Date of birth: Country of Citizenship:

7

Color of hair:

8

Color of eyes:

9

Sex:

10

Type of airman certificate(s) you hold:

□ Airline Transport □ ATC Specialist □ Commercial □ Flight Engineer □ Flight Instructor □ Flight Navigator □ Private □ Recreational □ Student □ None □ Other _____________________

11

Occupation (optional):

12

Employer (optional):

13

Has your FAA Airman Medical Certificate ever been denied, suspended, revoked, or withdrawn?

□ No □Yes If yes, give date ____/_______ MM/ YYYY

14. Omitted

15. Omitted

16

Date of Last FAA Medical Application

____/_______ MM / YYYY or □ No Prior Application (If no prior application, STOP. You cannot use BasicMed.)

17

Do You Currently Use Any Medication? (Prescription or over-the-counter) If additional space is needed, check this box □ and list information on an additional sheet of paper

□ No □Yes (If yes, list medication(s) and dosage used below.) Medication Name Dosage

17b.

Do you ever use near vision contact lens(es) while flying

□ No □Yes Answer “Yes” if you wear a contact in one eye only to correct for near vision or if you have one contact that adjusts for near vision and one in the other eye that adjusts for distant vision.

18

Medical History: Mark “Yes” if you have or had any of the following conditions at ANY TIME in your life. Explain when it occurred, the severity, how it was treated, and if you are currently taking any medication or having treatment for the condition or have to see a physician for the condition. Discuss any “Yes” responses with the physician doing this exam. Additional comments or explanations (Give details in the space below)

No

Yes

a.

Frequent or severe headaches:

b.

Dizziness or fainting spell:

c.

Unconsciousness for any reason:

d.

Eye or vision trouble (except for glasses):

e.

Hay fever or allergy:

f.

Asthma or lung disease:

g.

Heart or vascular trouble:

h.

High or low blood pressure:

i.

Stomach, liver, or intestinal trouble:

j.

Kidney stone or blood in urine:

k.

Diabetes:

l.

Neurological disorders (epilepsy, seizures, stroke, paralysis, etc.):

No

Yes

m.

Mental disorders of any sort (depression, anxiety, etc.):

n.

Substance dependence, failed a drug test ever, or substance abuse or use of illegal substance in the last 2 years:

o.

Alcohol dependence or abuse:

p.

Suicide attempt:

q.

Motion sickness requiring medication:

r.

Military medical discharge:

s.

Medical rejection by military service:

t.

Rejection for life or health insurance:

u.

Admitted to a hospital:

x.

Other illness, disability, or surgery:

v.

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.

History of non-traffic conviction(s) (misdemeanors or felonies): (e.g. battery, assault, public intoxication, robbery, etc.)

19.

Any visits to a health professional within the last 3 years? □ No □ Yes If “Yes,” list the date, name, address, type of provider and why you saw them. If additional space is needed, check this box □ and list information on an additional sheet of paper

Date Name Address Type of Provider Reason

Airman’s Signature and Declarations

In accordance with section 2307(b)(2)(A) of the FAA Extension, Safety, and Security Act of 2016 (Public Law 114-190), I affirm that:

□ The answers provided by me on this checklist, including my answers regarding my medical history, are true and complete;

□ I understand that I am prohibited under Federal Aviation Administration regulations from acting as pilot in command, or in any other capacity as a required flight crewmember, if I know or have reason to know of any medical deficiency or medically disqualifying condition that would make me unable to operate the aircraft in a safe manner; and

□ I am aware of the regulations pertaining to the prohibition on operations during medical deficiency and I have no medically disqualifying conditions in accordance with applicable law.

___________________________________________________________________________________________________________

Printed Name Airman Signature Date

NOTE: You must provide ALL sections (SECTION 1-3) of this checklist to your State-Licensed physician who will perform and complete the comprehensive medical examination as required by Section 2307(a)(7) of FESSA.

BasicMed SECTION 3: Instructions for State-Licensed Physician

This checklist is being submitted by an individual seeking to operate certain small aircraft in accordance with 14 CFR 61.113(i). This rule (BasicMed) allows pilots to use this checklist, and other requirements, in lieu of holding a FAA Airman Medical Certificate. The examination checklist may only be completed by a state-licensed physician. Under BasicMed, an individual may only act as Pilot In Command (PIC) of an aircraft that is authorized to carry not more than 6 occupants, and that has a maximum certificated takeoff weight of not more than 6,000 pounds.

As the examining physician, you are required to:

1. Review all sections of the checklist, particularly SECTION 2 completed by the airman.

2. Conduct a comprehensive medical examination in accordance with the checklist by:

   1. Examining each item specified;

   2. Exercising medical discretion, address, as medically appropriate, any medical conditions identified; and

   3. Exercising medical discretion, determine whether any medical tests are warranted as part of the comprehensive medical examination.

3. Review and discuss all prescription and non-prescription medication(s) the individual reports taking and any potential to interfere with the safe operation of an aircraft or motor vehicle.

4. Complete the Physician’s Signature and Declaration.

5. Complete the Physician’s Information.

You should consider consulting available aeromedical resources on the flight hazards associated with medical conditions/medications, to include:

• The FAA Guide for Aviation Medical Examiners (AME Guide) at http://www.faa.gov/go/ameguide;

• The FAA Pharmaceuticals (Therapeutic Medications) Do Not Issue - Do Not Fly list at http://www.faa.gov/go/dni;

• Chapter 8 of the FAA’s Aeronautical Information Manual (AIM 8-1-1), which addresses medical facts for pilots and is available at http://www.faa.gov/air_traffic/publications/;

• www.faa.gov/go/basicmed.

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)

BASICMED SECTION 3: MEDICAL EXAMINATION

(To be performed by state-licensed physician only)

	Physician Use Only
	Patient/Pilot name: Patient/Pilot Date of Birth:	Examined
1.	Head, face, neck and scalp:	□
2.	Nose, sinuses, mouth, and throat:	□
3.	Ears, general: (Internal and external (canals) and eardrums (perforation):	□
4.	Eyes (general), ophthalmoscopic, pupils, (equality and reaction), and ocular motility (associated parallel movement, nystagmus):	□
5.	Lungs and chest: (Not including breast examination):	□
6.	Heart: (precordial activity, rhythm, sounds, and murmurs):	□
7.	Vascular system: (pulse, amplitude, and character and arms, legs, and others):	□
8.	Abdomen and viscera: (including hernia):	□
9.	Anus: (not including digital examination):	□
10.	Skin:	□
11.	G-U system: (not including pelvic examination):	□
12.	Upper and lower extremities: (strength and range of motion):	□
13.	Spine and other musculoskeletal:	□
14.	Identifying body marks, scars, and tattoos (size and location):	□
15.	Lymphatics:	□
16.	Neurologic: (tendon reflexes, equilibrium, senses, cranial nerves, coordination, etc.):	□
17.	Psychiatric: (appearance, behavior, mood, communication, and memory):	□
18.	General systemic:	□
19.	Hearing:	□
20.	Vision: (distant, near, and intermediate vision, field of vision, color vision, and ocular alignment):	□
21.	Blood pressure and pulse:	□
22.	Anything else the physician, in his or her medical judgment, considers necessary.	□

In accordance with 14 CFR 68.5, the examining physician is instructed to:

• Exercise medical discretion to address, as medically appropriate, any medical conditions identified, and to exercise medical discretion in determining whether any medical tests are warranted as part of the comprehensive medical examination; and

• Discuss all drugs the individual reports taking (prescription and nonprescription) and their potential to interfere with the safe operation of an aircraft or motor vehicle.

Physician’s Signature and Declaration

□ In accordance with section 2307(b)(2)(C)(iv), of the FAA Extension, Safety, and Security Act of 2016 (Public Law 114-190), I certify that during the medical examination, I discussed all items on this checklist with the individual/patient whose name, signature, and other identifying information appears in SECTION 2 of this checklist and who is listed below under “Patient/Pilot Name”; discussed any medications the individual is taking that could interfere with his or her ability to safely operate an aircraft or motor vehicle; and performed an examination that included all of the items on this checklist. I certify that I am not aware of any medical condition that, as presently treated, could interfere with the individual's ability to safely operate an aircraft.

Patient/Pilot Name (printed) Patient/Pilot Date of Birth

Signature of Physician who performed the exam

Physician’s Information

1.	Full name of physician who performed the exam: Printed or Stamp	Last : First: Middle Initial:
2.	State license number:	State Medical license number
3.	Telephone number:	( ) __________ - __________________
4.	Street address:	Address: Suite: City: State: Zip Code:
5.	Date of Examination: _____	____/___/____ MM/ DD/ YYYY

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FAA 8700-2 Comprehensive Medical Examination Checklist