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File Type	application/pdf
File Title	8610006268.g
Author	RR_Donnelley
Last Modified By	Enterprise Prepress Services
File Modified	2020-05-08
File Created	2006-03-13
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UNITED STATES OF AMERICA

Department of Transportation
Federal Aviation Administration

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

GG-

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.
Height

Weight

Hair

Eyes

Sex

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.

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. Give the Applicant Copy to the applicant.

Limitations

Date of Birth

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; (d) sign the certificate in ink (both the AME and applicant must sign); and
(e) issue the signed certificate to the airman.

Examiner

Date of Examination

Examiner’s Designation No.

Signature
Typed Name

6. AME’s are required to use the electronic transmission capability of the Aerospace
Medical Certification System (AMCS) and must forward the FAA/Original Copy to
the FAA in Oklahoma (see address below). 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.

AIRMAN’S SIGNATURE

FAA Form 8420-2 (9-08) Supersedes Previous Edition

FAA AEROMEDICAL CERTIFICATION DIVISION
AAM-300
P.O. BOX 26080
OKLAHOMA CITY, OK 73125

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).

Passenger-Carrying Prohibited

STUDENT PILOT CERTIFICATE

A. To Solo The
Following Aircraft

B. To Make
Solo CrossCountry Flights

INSTRUCTIONS FOR ISSUANCE OF THIS MEDICAL CERTIFICATE

1. This certificate is for issuance to applicants other than those applying for a MedicalStudent 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):

Height

Weight

Hair

Eyes

Sex

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

Limitations

6. AME’s are required to use the electronic transmission capability of the Aerospace
Medical Certification System (AMCS) and must forward the FAA/Original Copy to the
FAA in Oklahoma (see address below). 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

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.

Examiner’s Designation No.

Signature
Typed Name

AIRMAN’S SIGNATURE

FAA Form 8500-9 (9-08) Supersedes Previous Edition

For all applicants except for Air Traffic Control Specialists to:
FAA AEROSPACE MEDICAL CERTIFICATION DIVISION
AAM-300
P.O. BOX 26080
OKLAHOMA CITY, OK 73125
For Air Traffic Control Specialist applicants to:
FAA REGIONAL FLIGHT SURGEON (RFS)
(address to appropriate RFS)

CONDITIONS OF ISSUE
The holder of this certificate must:
Have it in his or her personal possession at all times
while exercising privileges of an airman certificate.
(14CFR § 61.3)
Understand that the issuance of a medical certificate by
an Aviation Medical Examiner may be reversed by the
FAA within 60 days.
(14CFR § 67.407)
Comply with validity standards specified for first-,
second-, and third-class medical certificates.
(14CFR § 61.23)
Comply with any statement of functional, operational,
and/or time limitation issued as a condition of
certification.
(14CFR § 67.401)
(Note: A letter of authorization (or SODA) describing
any such limitations must be kept with this certificate at
all times while exercising the privileges of an airman
certificate.)
Comply with the standards relating to prohibitions on
operation during medical deficiency.
(14CFR §§ 61.53, 63.19, 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.

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 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 1.5 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 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 8500-8 (9-08) 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 legible 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 or 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 History - Letter (v)
of this subheading asks if you have ever been: (1) arrested and/
or 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) arrested, convicted 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 arrests and/or convictions
are not required to be reported if they did not involve: alcohol or a
drug; suspension, revocation,
cancellation,
or
denial
of
driving
privileges;
or
attendance at an educational or
rehabilitation program. If “yes” is checked, a description of the
arrest(s) and/or conviction(s) and/or administrative action(s) must
be given in the EXPLANATIONS box. The description must include:
(1) 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 arrests and/or convictions; etc.); (2) the name
of the state or other jurisdiction involved; and (3) the date of
the arrest(s) and/or conviction(s) and/or administrative action(s).
The FAA may check state motor vehicle driving licensing
records to verify your responses. Letter (w) of this subheading asks
if you have ever had any other (nontraffic) 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
EXPLANATIONS 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 (9-08) Supersedes Previous Edition

NSN: 0052-00-670-6002

Applicant Must Complete ALL 20 Items (Except For Shaded Areas) PLEASE PRINT

GG-

Copy of FAA Form 8500-9
(Medical Certificate) or FAA
Form 8420-2 (Medical/Student
Pilot Certificate) issued.

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
5. Address

Telephone Number (

)

—

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

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application

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

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

Examiner

9. Sex

Y Y Y Y

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

Signature
Typed Name

AIRMAN’S SIGNATURE

C
L
A

Yes

(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

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

Eye or vision trouble except glasses j.

Kidney stone or blood in urine

Alcohol dependence or abuse

Admission to hospital

Hay fever or allergy

Diabetes

Suicide attempt

Other illness, disability, or surgery

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

Motion sickness requiring medication y.

Asthma or lung disease

Medical disability benefits

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

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

— NOTICE —

See Instructions Page
Reason

20. Applicant’s National Driver Register and Certifying Declarations

Whoever in any matter within the I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to the FAA
jurisdiction of any department or information pertaining to my driving record. This consent constitutes authorization for a single access to the information contained in the NDR
agency of the United States to verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if any, available
knowingly and willingly falsifies, for my review and written comment. Authority: 23 U.S Code 401, Note.
conceals or covers up by any trick,
NOTE: ALL persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an
scheme, or device a material fact,
application for Medical Certificate or Medical Certificate and Student Pilot Certificate.
or who makes any false, fictitious
I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge,
or fraudulent statements or
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 understand the
representations, or entry, may be
Privacy Act statement that accompanies this form.
fined up to $250,000 or imprisoned
Signature of Applicant
Date
not more than 5 years, or both.
(18 U.S. Code Secs. 1001; 3571).
M M / D D / Y Y Y Y
FAA Form 8500-8 (9-08) Supersedes Previous Edition

NSN: 0052-00-670-6002

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.

Record Audiometric Speech
Discrimination Score Below

49. Hearing
Conversational
Voice Test at 6 Feet

Pass

Right Ear
Audiometer

1000

2000

Corrected to
Corrected to
Corrected to

20/
20/
20/

Left Ear
3000

4000

500

1000

2000

3000

4000

Threshold in
decibels

Fail

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

500

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

53. Field of Vision

20/
20/
20/

Right 20/
Left 20/
Both 20/

51.b. Intermediate Vision - 32 Inches

54. Heterophoria 20’ (in prism diopters)

Normal
Abnormal
55. Blood Pressure
Systolic
Diastolic

56. Pulse

Esophoria

Right 20/
Left 20/
Both 20/

Corrected to
Corrected to
Corrected to

Exophoria

Normal

(Sitting,
mm of Mercury)

Abnormal

Albumin

Pass
Fail

Right Hyperphoria

57. Urine Test (if abnormal, give results)

(Resting)

52. Color Vision

20/
20/
20/

Left Hyperphoria

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

Sugar

59. Other Tests Given

FOR FAA USE
Pathology Codes:

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.)

Coded By:

Clerical Reject
Significant Medical History

YES

Abnormal Physical Findings

YES

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 Y Y Y

Street Address
AME Serial Number
City

FAA Form 8500-8 (9-08) Supersedes Previous Edition

State

Zip Code

AME Telephone (

)
NSN: 0052-00-670-6002

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.

GG-

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
5. Address

Telephone Number (

)

—

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

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application

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

No Prior
Application

M M / D D / Y Y Y Y

Examiner

9. Sex

Y Y Y Y

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

Signature

Y
P
O

Typed Name

AIRMAN’S SIGNATURE

Yes

(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

Eye or vision trouble except glasses j.

Hay fever or allergy

O
W
E

Asthma or lung disease

Kidney stone or blood in urine
Diabetes

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

Alcohol dependence or abuse

Admission to hospital

Suicide attempt

Other illness, disability, or surgery

Motion sickness requiring medication y.

Medical disability benefits

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

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

— NOTICE —

Review Action Codes

See Instructions Page
Reason

20. Applicant’s National Driver Register and Certifying Declarations

NSN: 0052-00-670-6002

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.

GG-

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
5. Address

Telephone Number (

)

—

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

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application

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

No Prior
Application

M M / D D / Y Y Y Y

Examiner

9. Sex

Y Y Y Y

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

Signature
Typed Name

AIRMAN’S SIGNATURE

Yes

(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?

T
N
A

Yes

C
I
PL

Eye or vision trouble except glasses j.

Kidney stone or blood in urine

Alcohol dependence or abuse

Admission to hospital

Hay fever or allergy

Diabetes

Suicide attempt

Other illness, disability, or surgery

Motion sickness requiring medication y.

P
A

Asthma or lung disease

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

Medical disability benefits

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

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

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

— NOTICE —

Review Action Codes

See Instructions Page
Reason

20. Applicant’s National Driver Register and Certifying Declarations

NSN: 0052-00-670-6002