Form 8500-14 Ophthalmological Evaluation for Glaucoma

INFORMATION FOR APPLICANT
U.S. Department
of Transportation
Federal Aviation
Administration

OPHTHALMOLOGICAL EVALUATION FOR
GLAUCOMA
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 Burden 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 15 minutes 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 mandatory to be reported on occasion (as needed) based
on the duration of the three classes of medical certificates as specified in 14 CFR §61.3(d) and will vary
among respondents. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: Information Collection Clearance Officer,
Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.

Tear off this cover sheet before submitting this form

FAA Form 8500-14 (9-97) Supersedes Previous Edition

NSN: 0052-00-694-4003

Form Approved OMB No. 2120-0034
Expiration Date 06/30/2020

OPHTHALMOLOGICAL EVALUATION FOR GLAUCOMA

1. DATE

U S. DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION

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. FAMILY HISTORY OF GLAUCOMA

6. Diagnosis
A. TYPE (Check One)

Simple, W ide Angle, Open

Closed Angle, Narrow Angle. Angle Closure

B. DISCOVER -- e.g., routine examination, FAA physical examination, acute symptoms, reduction in visual acuity, etc.

C. CONFIRMATION -- Tonometric readings, gonioscopy visual fields, tonography, or provocative tests. GIVE METHODS, RESULTS AND DATE
CONFIRMED

7. SURGERY
A. IF SURGERY HAS BEEN PERFORMED, INDICATE WHICH EYE AND TYPE OF SURGERY.
B. IS SURGERY ANTICIPATED WITHIN 24 MONTHS?
YES, PROBABLE

NO, NOT LIKELY

8. INITIAL RESPONSE TO THERAPY -- Indicate results including strength, frequency and type of medication used at that time.

9. PRESENT TREATMENT -- Indicate exact type, strength, frequency, and name of medication being used.

10. ADEQUACY OF CONTROL
A. DESCRIBE PRIOR CONTROL, INCLUDING SERIAL TONOMETRIC FINDINGS, CHANGES IN VISUAL FIELDS, ETC.

B. MAXIMUM INTRAOCULAR PRESSURES IN RELATIONSHIP TO DAILY MEDICATION (If known).

C. INTRACOCULAR PRESSURE
O.D.

O.S.

TEST METHOD USED

TIME SINCE LAST MEDICATION

NOTE -- Pressures should NOT be taken within 2 hours after use of medication unless 10.B. is completed.

FAA FORM 8500-14 (9-97) Supersedes Previous Edition

NSN: 0052-00-667-4002

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11. FIELD OF VISION -- Record physiological and any pathological peripheral or central visual field losses from a perimeter and/or
tangent screen using white test object -- SUBMIT OR ATTACH CHARTS
A. DID EXAMINEE WEAR GLASSES OR CONTACT LENSES DURING
TEST? (Specify which)

B. SIZE OF TEST OBJECT USED WITH TANGENT
SCREEN

12. VISUAL ACUITY -- Record (Use Snellen linear values)
CORRECTED

UNCORRECTED

TEST METHOD USED

O. D.

A. DISTANT

O.S.

O. U.

O. D.

O.U.

O.D.

O.D.

B. NEAR

O.S.

O.D.

C. INTERMEDIATE
(32 INCHES)

O.S.

O.S.

O.U.

CORRECTED

UNCORRECTED

TEST METHOD USED

O. U.

CORRECTED

UNCORRECTED

TEST METHOD USED

O.S.

O.U.

O.D.

O.S.

O.U.

D. IMPORTANT -- If correction is needed and there is inability to correct either eye to 20/20 or better, give reasons.

13. PRESENT CORRECTION
DOES AIRMAN W EAR?

GLASSES

O.D.

O.S.

SPHERE-CYLINDER AXIS

SPHERE CYLINDER AXIS

CONTACT LENSES

14. PUPILS -- Statement of relative size and reaction of the pupils to accommodation and light, with special reference to any disease
process, healed or active

15. OPHTHALMOSCOPIC -- Describe any variations from normal in either eye on funduscopic examinations, with special reference to any
disease process, healed or active.

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

17. FUSION --Estimate fusion ability and state methods used in examination

18A. TYPED NAME AND ADDRESS OF EYE SPECIALIST

FAA FORM 8500-14 (9-97) Supersedes Previous Edition

18B. SIGNATURE OF EYE SPECIALIST

NSN: 0052-00-667-4002

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