Aeromedical Mental Health Evaluation Summary (SSRI/Psych History)

Aeromedical Mental Health Evaluation Status Report

Positioning Statement: This report is a clinical status summary prepared for aeromedical stakeholders. The author is not the certifying authority; all aeromedical certification decisions are made solely by the FAA and/or the AME/HIMS AME per applicable regulations and policies.

Patient Name: [Patient full name]

DOB: [DOB]

Date of Evaluation: [Date of evaluation] (If not a same-day examination, specify the date of the most recent clinical encounter informing this report.)

Author Name and Credentials: [Author name, degrees, license number, state]

Referral Source: [AME / HIMS AME / aeromedical authority / other requesting party]

Aviation Context: [Certificate class sought or held], [airman / ATCS], [current flight or operational status if known]

Authorization and Records

[Authorization statement documenting patient consent for release of this report and intended recipients, including date of authorization, scope, and any limitations]

Records Reviewed:

• Psychiatry/therapy notes: [Source and date range]
• Hospital/ED records: [Source and date range]
• Medication/pharmacy history: [Source and date range]
• Prior aeromedical correspondence: [Source and date range]
• Collateral documents: [Source and date range]
• [Other records reviewed with source and date range]

Reason for Report

[One to three sentences stating the purpose—initial certification, recertification, medication initiation, medication discontinuation, or history clarification—and the specific clinical questions addressed: stability, side effects, safety risk, functional status, prognosis]

Diagnosis and Treatment Timeline

(List key events in chronological order. Use additional bullet points as needed.)

• [Date or range]: [Diagnosis or clinical syndrome], [precipitating context], [key symptoms and severity], [treatment initiated or changed], [response or remission status], [safety events if any], [aeromedical impacts such as grounding or duty restrictions]
• [Additional timeline entries as needed]

Interpretive Course Summary: [Single episode vs recurrent], [remission stability and duration], [treatment responsiveness], [overall course characterization]

Explicit Historical Features: (Select one option for each item.)

• Psychotic symptoms (ever): [Present / Denied / Not assessed / Unknown or records unavailable]
• Suicidal ideation or attempts (ever): [Present / Denied / Not assessed / Unknown or records unavailable]
• Psychiatric hospitalization: [Present / Denied / Not assessed / Unknown or records unavailable]
• ECT/TMS/ketamine treatment: [Present / Denied / Not assessed / Unknown or records unavailable]
• Multi-agent psychotropic regimen (concurrent): [Present / Denied / Not assessed / Unknown or records unavailable]

Current Clinical Status

[Current diagnosis being treated], [level of symptom control], [duration at current baseline], [date of most recent exacerbation and resolution], [residual symptoms and functional impact]

Symptom Inventory: [Depressive symptoms], [anxiety symptoms], [PTSD/trauma symptoms], [OCD symptoms], [cognitive symptoms relevant to cockpit or operational performance including attention, working memory, processing speed], [sleep and circadian factors] (Describe presence, frequency, severity, and impact as applicable.)

Validated Scales: [Scale name, administration date, score, interpretation, and trend vs prior] (If no scales administered, document clinician-rated severity with brief rationale.)

Treatment History

Psychotherapy: [Modality], [dates], [frequency], [adherence], [response], [current status: active / completed / none] (If no therapy history, explicitly state "No psychotherapy history.")

Medications: (For each medication, include all relevant details. Emphasize sedation, cognitive effects, tremor, GI, and sexual side effects.)

• [Medication name]: [Indication]; started [start date]; [stop date if applicable]; [dose history with dates]; current dose [dose] since [date of last change]; [duration at current stable dose]; response: [remission / partial / none]; adverse effects: [specify or "none reported"]
• [Additional medications as needed]
• Past trials/augmentation: [List with key outcomes and reasons for discontinuation]

SSRI/Antidepressant Stability Statement: Patient has been clinically stable on [medication name] [dose] since [date], representing [number] continuous months on stable dose, with [no aeromedically significant side effects reported / side effects: specify].

Higher-Acuity Interventions: [Psychiatric hospitalizations with dates, reason, length, discharge diagnosis and medications], [ED or urgent evaluations], [involuntary evaluations], [neuromodulation treatments] (If none, state: "No history of psychiatric hospitalization, involuntary evaluation, or neuromodulation treatment.")

Safety Assessment

(This section is mandatory and must not be omitted.)

Suicide/Self-Harm Risk:

• Current SI: [None / Passive / Active]; plan: [yes / no]; intent: [yes / no]; means access: [yes / no / specify]
• Lifetime history: [SI history], [attempt history], [NSSI history] with dates and context if available
• Acute risk factors: [List or "none identified"]; Protective factors: [List]
• Overall risk level: [Low / Moderate / High] with brief justification
• Mitigation: [Safety plan elements], [crisis resources provided], [lethal means counseling], [follow-up interval]

Violence/Aggression Risk:

• Homicidal ideation: [Present / Denied]; Threat history: [Specify / Denied]
• Domestic violence history: [Present / Denied]; Weapon access: [Yes / No / Unknown]
• Legal/disciplinary events: [Specify / Denied]
• Overall impression: [Low / Moderate / High] risk with rationale

Aviation Safety Impairment Statement: [Explicit statement addressing presence or absence of: impulsivity, psychosis, panic attacks, dissociation, severe insomnia, medication adverse effects impairing performance, substance misuse, and cognitive impairment, with statement of whether any pose aeromedically significant risk]

Substance Use

• Alcohol: [Pattern, frequency, quantity], [AUD history and treatment if any], [last use if relevant]
• Cannabis: [Current / Past / Never], [last use date if past]
• Illicit substances or prescription misuse: [Specify / Denied]
• Tobacco/nicotine: [Current / Past / Never], [form and quantity]
• Substance-related hospitalizations or legal events: [Specify / Denied]

(If no relevant history, state: "No history of substance use disorder or aeromedically significant substance use.")

Functional Assessment

Occupational: [Attendance], [performance], [disciplinary actions], [accommodations], [duty changes or grounding episodes with reason]

Aviation-Specific: [Current flight or operational status], [last flight date if grounded], [in-flight symptoms such as panic, dissociation, attention lapses, or near-miss events—state "none reported" if asked and denied], [crew resource functioning observations if available]

Psychosocial: [Relationship stability], [major stressors], [coping strategies], [sleep regularity], [treatment adherence]

Mental Status Examination

(If this is a summary without same-day examination, state the date of the most recent MSE.)

• Appearance/behavior: [Description]; Psychomotor activity: [Normal / Increased / Decreased]
• Speech: [Rate, volume, prosody]
• Mood: [Patient-stated mood]; Affect: [Range, reactivity, congruence]
• Thought process: [Linear and goal-directed / Circumstantial / Tangential / Other]; Thought content: [SI, HI, delusions, obsessions—present or denied]
• Perceptions: [Hallucinations or illusions—present or denied]
• Cognition: [Orientation], [attention], [memory], [executive function observations]
• Insight: [Intact / Fair / Limited]; Judgment: [Intact / Fair / Limited]
• Reliability/validity: [Cooperation, effort, consistency with collateral and records]

Assessment

(List active and historically significant diagnoses. Note differentials only if clinically relevant.)

• [Diagnosis with code if available]: Status: [Active / In remission / Resolved]; Severity: [Mild / Moderate / Severe] with basis; Aeromedical significance: [Risk of sudden or subtle incapacitation, adequacy of symptom control, medication side effects relevant to safety-sensitive performance]
• [Additional diagnoses as needed]
• Differential diagnosis (if applicable): [Diagnosis] — [Brief rationale]

Plan, Prognosis, and Monitoring

Treatment Plan: [Continue or modify medications], [therapy continuation or referral], [planned taper if applicable]

Monitoring Plan: [Follow-up interval], [clinician responsible for monitoring], [symptom tracking method], [side effect monitoring approach], [substance monitoring if indicated with frequency]

Communication Plan: [Who is notified if deterioration occurs], [what constitutes a reportable change: dose change, new medication, symptom relapse, safety event, hospitalization], [notification method and timing]

Prognosis: [Expected course], [relapse risk indicators], [stability expectations]

(If medication discontinuation is planned, include: taper schedule with dates, required observation period duration, monitoring steps during and after taper, and instruction that flying or operational duties should cease if symptomatic or experiencing side effects.)

Disposition Summary

[Three to six sentences summarizing: current symptom stability, medication stability and side effect status, safety risk conclusion with mitigation steps, and functional status for aviation duties. Conclude with explicit statement that aeromedical certification determination rests with the FAA/AME.]

Signature

Clinician Signature: [Signature]

Credentials and License: [Degrees, license number, state]

Contact Information: [Practice name, address, phone, secure email or fax]