W:\WPDOCS\CURRENT\PDF\FAA

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.

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. "Substance dependence" is defined by any of the following:

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 appli-

cable 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.

17a. 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.

17b. 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 EX-

PLANATIONS box, but you must still check "yes" to the condition. Do

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

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.

Conviction and/or Administrative Action History -- Letter (v) of this

subheading asks if you have ever been: (1) 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) 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 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 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 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.); (2) the name

of the state or other jurisdiction involved; and (3) the date of the

conviction and/or administrative action. The FAA may check state

motor vehicle driver 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.

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

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

Form Approved OMB NO. 2120-0034

Copy of FAA Form 8500-8

(Medical Certificate) or FAA

Form B420-2 Medical/Student

Pilot Certificate) issued.

MEDICAL CERTIFICATE___________CLASS

AND STUDENT PILOT CERTIFICATE

FF- 1953420

This certifies that (Full name and address):

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.

LimitationsExaminer

Signature

Typed Name

AIRMAN'S SIGNATURE

Date of Examination Examiner's Designation No.

1. Application For:

Airman Medical

Certificate

Airman Medical and

Student Pilot Certificate

2. Class of Medical Certificate Applied For:

1st

2nd 3rd

3. Last Name

First Name Middle Name

4. Social Security Number

5. Address

Telephone Number ( )

Number / Street

City

State / Country

Zip Code

6. Date of Birth

7. Color of Hair 8. Color of Eyes 9. Sex

Citizenship

M M / D D / Y Y Y Y

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

None

Airline Transport

Commercial

ATC Specialist

Flight Engineer

Flight Navigator

Flight Instructor

Private

Student

Recreational

Other

11. Occupaton 12. Employer

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

Yes No

If yes, give date

M M / D D / Y Y Y Y

Total Pilot Time

(Civilian Only)

14. To Date 15. Past 6 months

16. Date of Last FAA Medical Application

M M / D D / Y Y Y Y

No Prior

Application

17a. Do You Currently Use Any Medication (Prescription or Nonprescription)?

No Yes

(If yes, below list medication(s) used and check appropriate box).

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

Yes No

Previously Reported

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

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

NoYes

Frequent or severe headaches

Dizziness or fainting spell

Unconsciousness for any reason

Eye or vision trouble except glasses

Hay fever or allergy

Asthma or lung disease

Heart or vascular trouble

High or low blood pressure

Stomach, liver, or intestinal trouble

Kidney stone or blood in urine

Diabetes

Neurological disorders; epilepsy,

seizures, stroke, paralysis, etc.

Mental disorders of any sort;

depression, anxiety, etc.

Substance dependence or failed a

drug test ever, or susbstance abuse

or use of illegal substance in the

last 2 years.

Alcohol dependence or abuse

Suicide attempt

Motion sickness requiring

medication

Military medical discharge

Medical rejection by military service

Rejection for life or health insurance

Admission to hospital

Other illness, disability, or surgery

NoYes NoYes NoYesCondition Condition Condition Condition

Conviction and/or Administrative Action History — See Instructions Page

NoYes

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.

NoYes

History of nontraffic

conviction(s)

(misdemeanors or felonies).

Explanations: See Instructions Page

19. Visits to Health Professional Within Last 3 Years.

Yes

(Explain Below)

See Instructions Page

FOR FAA USE

Review Action Codes

Date Name, Address, and Type of Health Professional Consulted Reason

— NOTICE —

Whoever in any matter within the

jurisdiction of any department or

agency of the United States

knowingly and willfully falsifies,

conceals or covers up by any trick,

scheme, or device a material fact,

or who makes any false, fictitious or

fraudulent statements or repre-

sentations, 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)

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 the FAA

information pertaining to my driving record. This consent constitutes authorization for a single access to the information contained 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 my knowledge, 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 Privacy Act

statement that accompanies this form.

Signature of Applicant Date

M M / D D / Y Y Y Y

FAA Form 8500-8

(3-00) Supersedes Previous Edition

NSN-0052-00-670-6002

(Tendon reflexes, equilibrium, senses,

cranial nerves, coordination, etc.)

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)

G Yes G No Defect Noted:

24. SODA Serial Number

CHECK EACH ITEM IN APPROPRIATE COLUMN

Normal Abnormal

CHECK EACH ITEM IN APPROPRIATE COLUMN

Normal Abnormal

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

32. Ophthalmoscopic 44. Identifying body marks, scars, tattoos (Size and location)

33.

Pupils (Equality and reaction)

45.

Lymphatics

34. Ocular motility (Associated parallel movement, nystagmus) 46. Neurologic

35.

Lungs and chest (Not including breast examination)

47.

Psychiatric (Appearance, behavior, mood, communication, and memory)

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

Record Audiometric Speech

Discrimination Score Below

Right Ear Left Ear

Conversational

Voice Test at 6 Feet

G Pass G Fail

Audiometer

Threshold in

Decibels

500 1000 2000 3000 4000 500 1000 2000 3000 4000

50. Distant Vision

Right

20/ Corrected to 20/

Left

20/ Corrected to 20/

Both 20/ Corrected to 20/

51.a. Near Vision

Right

20/ Corrected to 20/

Left

20/ Corrected to 20/

Both 20/ Corrected to 20/

51.b. Intermediate Vision – 32 Inches

Right

20/ Corrected to 20/

Left

20/ Corrected to 20/

Both 20/ Corrected to 20/

52. Color Vision

G Pass

G Fail

53. Field of Vision

G Normal G Abnormal

54. Heterophoria 20' (in prism diopters) Esophoria Expophoria Right Hyperphoria Left Hyperphoria

55. Blood Pressure 56. Pulse

(Resting)

57. Urinalysis (if abnormal, give results)

G Normal G Abnormal

58. ECG (Date)

(Sitting,

mm of Mercury)

Systolic Diastolic Albumin Sugar M M D D Y Y Y Y

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:

Significant Medical History G YES G NO Abnormal Physical Findings G YES G NO

Clerical Reject

61. Applicant's Name 62. Has Been Issued -- G Medical Certificate G Medical & Student Pilot Certificate

G No Certificate Issued -- Deferred for Further Evaluation

G Has Been Denied -- Letter of Denial Issued (Copy Attached)

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 State Zip Code AME Telephone ( )

FAA Form 8500-8 (7-92) Supersedes Previous Editions