Aeromedical Hypertension Evaluation Note

Encounter Date/Time: [date and time]

Author: [name, credentials, role - AME / treating clinician / aeromedical consultant]

Patient: [full name, DOB]

Certificate Context: [certificate class sought/held (1st/2nd/3rd), next exam date if known] (State "Not provided" if unknown; do not infer.)

Prepared For: [AME name / "FAA aeromedical review" / other requesting authority]

Aeromedical Purpose Statement

[Purpose statement: reason for evaluation, whether author is making a certification recommendation versus documenting medical facts for AME/agency decision]

Records Reviewed: [list records reviewed, e.g., clinic vitals, home BP log, ambulatory BP monitoring reports, pharmacy records, cardiology notes, labs, ECG] (List only items actually reviewed.)

Certification Snapshot

• BP at Evaluation: [SBP/DBP mmHg, position, setting, technique]
• Hypertension Symptoms: [none / present - specify if present]
• Antihypertensive Regimen: [medications with doses; total component count = X] (Count combination pills as multiple components.)
• Medication Tolerance: [no adverse effects / adverse effects present - specify if present, particularly dizziness, orthostasis, fatigue, cognitive effects, sedation]
• Stability on Current Regimen: [≥7 days / <7 days / unknown]
• Ground Trial Required: [yes / no] (If yes, include medication changed, start date, end date, and whether completed without adverse effects; do not infer completion.)
• Unacceptable Medications Used: [yes / no] (If yes, list agents. Unacceptable agents include clonidine, methyldopa, reserpine, guanfacine, guanabenz, nitrates.)
• Secondary Cause or Relevant Comorbidity: [yes / no] (If yes, list.)
• End-Organ Damage: [yes / no] (If yes, list.)
• Bottom Line: [Findings support controlled hypertension on stable regimen without adverse effects / Findings suggest uncontrolled or complex hypertension - additional review recommended] (Phrase as documentation support, not as a certification determination.)

(Complete all checklist fields. If information is unavailable, state "not available" or "unknown" rather than leaving blank.)

History of Present Illness

[Hypertension history and current status: diagnosis timeline, control history over the last 3–12 months with typical clinic and home ranges, variability, white-coat or masked patterns if data supports; prior treatments tried and reasons for discontinuation; current symptoms relevant to hypertension and medication safety; triggers and exacerbators; adherence and self-monitoring practices] (Use explicit negative statements for symptoms, e.g., "denies headache, visual changes, chest pain, dyspnea, palpitations, syncope, presyncope, orthostatic symptoms, focal neurologic deficits.")

Blood Pressure Data

Measurement Technique: [position, rest period, cuff size, arm used, automated vs manual, number of readings, averaging method, contextual factors]

Current Visit Readings:

• [Date/time, SBP/DBP mmHg, HR, position, setting] (List each reading in sequence, including any initial elevated values with explanation.)

Home Log / Ambulatory BP Monitoring: [date range, number of readings, average, range, interpretation as controlled vs uncontrolled, variability patterns] (If not provided, state "Not provided" and note whether obtaining such data was recommended.)

Medications

Antihypertensive Regimen

• [Medication name (generic), dose, route, frequency, start date, date of last dose change, aeromedical acceptability status] (List each agent on its own line.)

Total component count: [number] (Count combination pills by components.)

Other Relevant Medications

• [Medication name and indication] (Include agents affecting BP or alertness: stimulants, sedatives, decongestants, weight-loss agents, NSAIDs.)

Medication Side Effects

[Operationally significant symptoms] (Use explicit statements: denies dizziness, orthostatic symptoms, fatigue, somnolence, cognitive slowing, visual disturbance, exercise intolerance, bradycardia symptoms, nocturia, dehydration.)

Medication Change / Ground Trial

(Include only if a medication was recently started or adjusted.)

• Change: [what was changed and why]
• Ground trial interval: [start date] to [end date] (State "unknown" if dates not confirmed.)
• Tolerance during trial: [completed without adverse effects / adverse effects occurred - specify]
• Counseling: [patient counseled not to fly if adverse effects occur during observation period]

Comorbidities and Risk Factors

• [Secondary hypertension considerations: OSA and treatment status, kidney disease, endocrine causes] (Include only if clinically relevant.)
• [Cardiometabolic risk factors: diabetes/prediabetes, dyslipidemia, tobacco/nicotine, obesity, family history of premature CVD]
• [Lifestyle contributors: dietary sodium, alcohol, exercise, sleep, stress]

End-Organ Assessment

• Cardiac: [CAD/MI, heart failure, LVH/cardiomyopathy, arrhythmia - history and objective evidence] (If stating no evidence, specify what was reviewed, e.g., "no LVH on ECG [date].")
• Cerebrovascular: [TIA, stroke - history and objective evidence]
• Renal: [CKD, proteinuria/albuminuria, renal insufficiency - history and labs with dates]
• Ophthalmologic: [retinopathy status and exam date] (Include only if assessed.)
• Peripheral vascular: [findings] (Include only if present.)

(When stating absence of end-organ damage, specify supporting evidence; otherwise limit to "no known history of...")

Objective Findings

Vitals

BP: [readings as documented above]

HR: [value]

Height/Weight/BMI: [values]

Orthostatic vitals: [values] (Include if symptoms, high-risk medications, or recent dose change; otherwise omit.)

Physical Exam

[Focused cardiovascular exam: rate, rhythm, murmurs, edema; additional pulmonary, neurologic, or fundoscopic findings if clinically indicated] (Avoid extensive templated normal statements.)

Relevant Testing

• ECG: [date, key findings] (Include if performed or required for certificate class/age.)
• Renal function/electrolytes: [date, key results]
• Urinalysis/urine albumin: [date, key results]
• Glucose/A1c and lipids: [date, key results]
• [Other relevant tests with date and findings]

(For tests not performed or unavailable, state "Not performed" or "Not available" with rationale if clinically important.)

Assessment

[Hypertension assessment: control status (well-controlled / uncontrolled / possible white-coat effect), operational interpretation of whether findings support controlled hypertension on stable regimen without adverse effects or whether additional titration/evaluation is needed, secondary cause considerations if supported by findings] (Do not make definitive statements beyond available evidence.)

Plan

Aeromedical Clearance Support

• BP meets aeromedical thresholds: [yes / no; state values]
• Acceptable medication categories: [yes / no]
• Medication count within limits: [yes / no; total component count]
• Stable on current regimen ≥7 days: [yes / no / unknown]
• Ground trial currently required: [yes / no] (If yes, include dates and agents.)
• Attachments provided: [BP log, labs, ECG, specialist notes]

Clinical Management

• [Medication plan: continuation or adjustment with rationale]
• [Lifestyle counseling: salt reduction, weight, exercise, alcohol moderation, sleep, stress]
• [Follow-up interval and monitoring requirements]
• [Return precautions: severe BP with symptoms, neurologic deficits, chest pain]

Self-Grounding Counseling

[Documentation that patient was counseled regarding self-grounding obligations: do not fly if symptoms or medication effects impair safety, or during medication observation period; examples discussed such as syncope, significant dizziness, sedation, chest pain, neurologic deficits]

Signature

Clinician Signature: [signature]

Credentials: [credentials]

Date/Time: [date and time]