Aeromedical Status Report (Obstructive Sleep Apnea)

Report Type: [Initial / Recertification]

Date of Report: [Date]

Treating Clinician: [Name], [Credentials], [Specialty], [Clinic name], [Contact information]

Patient Name: [Full name]

Date of Birth: [DOB]

Aeromedical Identifiers: [Applicant ID / Reference number / Other identifier / Not provided]

Medical Certificate Class: [Class 1 / Class 2 / Class 3 / Not provided]

Addressee: [AME name and clinic if known, otherwise "For Aeromedical Certification Review"]

Clinical Summary

[Brief summary of diagnosis, treatment modality, current clinical stability, and objective evidence of adherence and efficacy] (Provide 2–3 sentences orienting the reviewer to the case status.)

Diagnostic Basis

• Diagnostic Sleep Study: [Date], [Type I/II in-lab polysomnogram / Type III/IV home sleep apnea test]
• Key Findings: Baseline [AHI / REI] [value] events/hour, oxygen saturation nadir [value]%, time SpO2 <90% [value or not reported]
• Primary Diagnosis: [Obstructive sleep apnea / Central sleep apnea / Complex sleep apnea / Other]
• Central Apnea Index: [value] events/hour (Include for Initial reports when available)
• Periodic Limb Movement Index: [value] events/hour (Include for Initial reports when available)

(If original study is unavailable, clearly label any figures as patient-reported and note source.)

Current Treatment

• Treatment Modality: [CPAP / APAP / BiPAP / Oral appliance / Positional therapy device / Hypoglossal nerve stimulator / Surgical intervention / Conservative management]
• Treatment Start Date: [Date]
• Treatment Changes: [Significant changes including setting adjustments, mask/interface changes, device replacement, or surgical dates]
• Tolerance and Side Effects: [Description of tolerance, comfort, and any side effects impacting use or performance]
• Availability and Continuity: [Any intermittent unavailability such as travel or device issues, frequency, and mitigation steps] (If not applicable, state "No interruptions in therapy")

PAP Adherence and Efficacy

(Include this section only when PAP therapy is the treatment modality.)

• Data Source: [Device manufacturer and model], objective device download
• Date Range Covered: [Start date] – [End date] (Initial: minimum 30 days; Recertification: up to past 12 months when available. If less data is available, explain why.)
• Days Used / Total Days: [value] / [value]
• Percent of Sleep Periods Used: [value]%
• Average Usage on Days Used: [HH:MM]
• Residual AHI on Treatment: [value] events/hour
• Leak Status: [Median / 95th percentile] [value and units], [clinically acceptable / elevated]
• Pressure Settings: [Fixed CPAP: X cmH2O / APAP: Min–Max cmH2O / BiPAP: IPAP/EPAP cmH2O]

(If multiple PAP devices are used, provide data for each device and note that the assessment reflects cumulative use.)

Interpretation: Adherence [meets / does not meet] aeromedical targets (≥75% of sleep periods used with average ≥6 hours per sleep period). Residual AHI [is controlled at ≤5 / is not fully controlled at >5]. [No concerns / Concerns exist] regarding treatment efficacy. [Brief justification if concerns noted.]

Non-PAP Therapy

(Include this section only when treatment is a dental/oral appliance, positional device, hypoglossal nerve stimulator, or surgical intervention.)

• Therapy Details: [Specific device or procedure], [Managing provider if applicable], [Date initiated], [Current settings or adjustments]
• Adherence: [Patient-reported use pattern and any available objective monitoring data]
• Efficacy Evidence: [Post-treatment sleep study results if performed], [Residual symptoms], [Current sleepiness assessment]
• Cardiovascular Comorbidities of Concern: Atrial fibrillation [present / absent], heart failure [present / absent], coronary artery disease [present / absent]

Residual Sleepiness Assessment

• Symptoms: Excessive daytime sleepiness [present / absent], unintentional dozing in passive situations [present / absent], morning headaches [present / absent], cognitive changes affecting attention or concentration [present / absent], non-restorative sleep [present / absent]
• Safety-Critical Functioning: Sleepiness while driving [present / absent], near-miss events or accidents plausibly related to fatigue [present / absent], daytime napping [frequency or none]
• Epworth Sleepiness Scale: [Score]/24 on [Date] (If ESS not used, state alternative instrument and rationale.)

Clinical Impression: [Integrated statement combining subjective symptoms, ESS score, objective therapy data, and examination findings.] There [is / is not] concern for residual daytime sleepiness. (This explicit statement is required for aeromedical processing.)

Relevant Comorbidities

• Hypertension: [Present / Absent], [number of medications], [controlled / uncontrolled]
• Atrial Fibrillation or Other Arrhythmia: [Present / Absent]
• Heart Failure: [Present / Absent]
• Coronary Artery Disease: [Present / Absent]
• Diabetes: [Present / Absent]
• History of Stroke: [Present / Absent]
• Anthropometrics: Weight [value], BMI [value], weight change since diagnosis or last review [value or stable]

Sedating Medications

[List all sedating or sleep medications including prescription and OTC agents: medication name, dose, frequency, indication. Document whether taken only when off-duty and any next-day impairment.] (If no sedating medications, explicitly state: "No sedating medications reported." Do not leave blank.)

Assessment

[Concise problem-focused assessment stating diagnosis and treatment modality with stability status. Address adherence adequacy with objective data, residual AHI control, and whether there is concern for residual daytime sleepiness. If treatment is not adequately controlled, identify limiting factors and immediate safety advice.]

Plan

• Therapy Continuation/Adjustments: [Ongoing treatment plan and troubleshooting steps as needed]
• Monitoring: [Follow-up interval], [Planned data reviews or repeat studies if indicated]
• Triggers for Earlier Reassessment: Return of sleepiness, significant weight gain, new cardiovascular comorbidity, treatment intolerance, or device failure

Attachments

• Diagnostic sleep study report ([Date]): [Attached / Pending / Not available – reason and expected availability]
• PAP device download report ([Date range], [Device]): [Attached / Pending / Not available – reason] (Include for PAP therapy)
• Epworth Sleepiness Scale questionnaire ([Date]): [Attached / Pending / Not available – reason]
• Dental appliance report from managing dentist: [Attached / Pending / Not available – reason / Not applicable]
• Post-treatment sleep study: [Attached / Pending / Not available – reason / Not applicable]
• Compliance attestation: [Attached / Pending / Not available – reason / Not required]

Signature: ______________________

Printed Name and Credentials: [Name, Credentials]

Date: [Date]

(Meta-instructions: Do not omit required fields. If information is not available, include the field with "Not provided" or "Pending" and expected availability. Ensure Report Type is clearly documented. For PAP users, provide objective adherence metrics with actual hours and minutes, not insurance-style compliance flags.)