Pre FAA Medical Exam | Champlain Medical Urgent Care

Fields with * are required.

Part 1

Company Name *

First Name *

Last Name *

Birthdate *

Contact Email *

What medications do you currently take *

Part 2

Have you ever had or do you currently have?

1. Frequent or severe headaches 1. Frequent or severe headaches *

Yes No

For example: Chronic (daily or weekly) headaches, headaches that have required medical treatment, migraine headaches, cluster headaches, or headaches associated with visual or neurological symptoms.

2. Dizziness or fainting spell 2. Dizziness or fainting spell *

Yes No

For example: Frequent spinning or lightheadedness; other factors associated with episodes of dizziness or fainting, such as headache, nausea, loss of consciousness, tingling, numbness, vertigo.

3. Unconsciousness for any reason 3. Unconsciousness for any reason *

Yes No

For example: Unconsciousness, no matter how short, whether explained or unexplained.

4. Eye or vision trouble except glasses 4. Eye or vision trouble except glasses *

Yes No

For example: Unusual visual experiences (halos, wavy lines, etc.), sensitivity to light, eye injury, loss of vision, vision discomfort, eye surgery.

5. Hay fever or allergy 5. Hay fever or allergy *

Yes No

For example: Chronic or seasonal allergies controlled by allergy shots and/or medication, nasal allergies, nasal obstruction, sinus block, sinusitis.

6. Asthma or lung disease 6. Asthma or lung disease *

Yes No

For example: Asthma attacks; use of an inhaler; COPD; chronic bronchitis; emphysema; fistula; fungal disease; pleurisy; pneumothorax; pulmonary embolism; pulmonary fibrosis; chest surgery; tumor(s).

7. Heart or vascular trouble 7. Heart or vascular trouble *

Yes No

For example: Angina, heart pain, coronary heart disease, heart attack, myocardial infarction, abnormal rhythm, atrial fibrillation, cardioversion, cardiac failure, congestive heart failure, heart enlargement, cardiac decompensation, hypertrophy or dilation of the heart, pulmonary hypertension, heart valve disease, heart valve repair or replacement, pacemaker, anti-tachycardia device, implantable defibrillator, congenital heart disease, endocarditis, heart inflammation, pericarditis or heart transplant.

8. High or low blood pressure 8. High or low blood pressure *

Yes No

For example: Diagnosis of high or low blood pressure, whether treated or not; use of blood pressure medication of any kind.

9. Stomach, liver, or intestinal trouble 9. Stomach, liver, or intestinal trouble *

Yes No

For example: Appendicitis, bleeding ulcer, bowel obstruction, cancer, Crohn's disease, chronic hepatitis, cirrhosis, colostomy, irritable bowel syndrome, hernia, ulcerative colitis, any surgery.

10. Kidney stone or blood in urine 10. Kidney stone or blood in urine *

Yes No

For example: Kidney stone, kidney cancer, kidney transplant, blood in urine, chronic recurrent urinary tract infections, urinating frequently at night.

11. Diabetes 11. Diabetes *

Yes No

For example: Pre-diabetes, type I diabetes, or type II diabetes treated with insulin, medication (oral or injectable), and/or diet and exercise.

12. Neurological disorders: epilepsy, seizures, stroke, paralysis, etc. 12. Neurological disorders: epilepsy, seizures, stroke, paralysis, etc. *

Yes No

Also, muscle weakness, disturbance of sensation, disturbance of consciousness, loss of coordination, head injury, concussion.

13. Mental disorders of any sort: depression, anxiety, etc. 13. Mental disorders of any sort: depression, anxiety, etc. *

Yes No

Also, attention deficit disorder, attention deficit hyperactivity disorder, bipolar disorder, obsessive compulsive disorder, panic attacks, personality disorder, post-traumatic stress disorder, psychosis.

Part 3

14. Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years. 14. Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years. *

Yes No

For example: Select Yes if you have been diagnosed and/or treated in an inpatient or outpatient setting for substance use. Select Yes if you ever had a diagnosis of substance use disorder. Select Yes for any and all positive drug tests whether administered at the federal, state, or local level, or by a private employer. For a detailed description of substance, substance dependence, substance abuse, and drug and alcohol testing, refer to 14 CFR §67.107, §67.207, §67.307, paragraphs (a)(4) and (b).

15. Alcohol dependence or abuse 15. Alcohol dependence or abuse *

Yes No

For example: Select Yes if you have been diagnosed and/or treated in an inpatient or outpatient setting for misuse of alcohol. Select Yes if you ever had a diagnosis of alcohol use disorder. Select Yes for any and all positive alcohol tests whether administered at the federal, state, or local level, or by a private employer. For a detailed description of substance, substance dependence, substance abuse, and drug and alcohol testing, refer to 14 CFR §67.107, §67.207, §67.307, paragraphs (a)(4) and (b).

16. Suicide attempt 16. Suicide attempt *

Yes No

For example: Thoughts of suicide, attempted suicide.

17. Motion sickness requiring medication 17. Motion sickness requiring medication *

Yes No

For example: Unresolved, chronic motion sickness (in flight while traveling by other vehicle) for which you must be medicated.

18. Admission to hospital 18. Admission to hospital *

Yes No

List any hospitalization(s) not already reported in the APPLICANT EXPLANATION box in relation to items 18a-y.

19. Other illness, disability, or surgery 19. Other illness, disability, or surgery *

Yes No

List any illness/illnesses or disability/disabilities not provided for in 18a-y.

20. Military medical discharge 20. Military medical discharge *

Yes No

21. Medical rejection by military service 21. Medical rejection by military service *

Yes No

22. Rejection for life or health insurance 22. Rejection for life or health insurance *

Yes No

23. Medical disability benefits 23. Medical disability benefits *

Yes No

24. History of (1) any arrest(s) and/or conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; 24. History of (1) any arrest(s) and/or conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; *

Yes No

25. History of any arrest(s), and/or conviction(s), and/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. 25. History of any arrest(s), and/or conviction(s), and/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. *

Yes No

26. History of nontraffic conviction(s) (misdemeanors or felonies) 26. History of nontraffic conviction(s) (misdemeanors or felonies) *

Yes No