Aerospace Medicine Consultation/Referral Letter

Date: [DD Mon YYYY]

From: [Sender name], [Credentials], [Role: Flight Surgeon / AME / Occupational Medicine Physician]; [Organization]; [Direct phone]; [Secure email]

To: [Recipient name], [Credentials]; [Department/Agency]; [ATTN: Office/Program/Case Manager]; [Office Symbol]; [Full mailing address]; [Secure fax or secure email]

Subject: [Patient full name]; DOB: [DD Mon YYYY]; [Aeromedical identifiers: certificate/case number]; [Duty/certification category: FAA Class I / FAA Class II / FAA Class III / Military Aviation Class / ATC]

Confidentiality Notice: [Confidentiality statement instructing that information is intended only for the addressee; misdirected recipients should notify sender and destroy all copies] (Include only for external recipients)

Reason for Referral

[Concise referral question framed up front] (3–6 sentences. State the aeromedical decision sought: clearance/disposition, limitations, waiver recommendation, specific testing, or return-to-duty determination. State what triggered the consult: [new diagnosis / symptom change / medication change / event / return-to-duty request / periodic re-evaluation]. Indicate urgency as [routine / time-critical] with brief rationale. Note key attached records.)

Operational Context

• [Role and platform: pilot / ATC / aircrew / mission specialist; aircraft/mission type; single-pilot / multi-crew]
• [Relevant operational stressors: altitude/hypoxia, G exposure, NVG use, shift work, ejection risk, other] (Include only those applicable)
• [Current duty status: grounded since [date] / restricted to [limitation] / flying without limitation since [date]]
• [Operational details not provided; specify needed details] (Include only if information is missing)

Clinical Synopsis

[Working diagnosis and certainty level]; [current severity]; [trajectory: improving / stable / worsening] with time anchors. [Key symptoms and functional impact on aviation/ATC tasks]. [Current medications with dose, frequency, start date, and flight-safety-relevant side effects]. [Pertinent history affecting recurrence risk or operational safety: prior syncope, seizures, arrhythmias, significant psychiatric or substance use history, prior aeromedical waivers or denials]. (Use specific dates throughout; define acronyms at first use.)

• [Timeline event with date] (Add or remove timeline items as needed for cases with multiple events)

Objective findings and key results: [Focused exam findings]; [Vital signs]; [Key diagnostics with dates: labs with units and reference ranges for abnormal values, imaging impressions, ECG/echo, stress test, sleep study, neurocognitive testing, other]. (Attach full reports; state explicitly if results are pending.)

[Medication reconciliation: complete / not available] (If not available, state explicitly and request under Consultant Requests)

Aeromedical Assessment & Consultant Requests

Assessment: [Condition/diagnosis]. [Clinical status: controlled / partially controlled / uncontrolled] with supporting evidence. [Operational relevance: why this condition matters for safety-critical duties]. [Risk characterization: risk of sudden incapacitation; risk of subtle performance decrement affecting attention, reaction time, judgment; risk of recurrence under operational stressors]. [Medication/treatment compatibility with safety-critical duty]. [Prognosis and monitoring needs]. [Controlling standard: FAA Guide for AMEs / Service-specific aeromedical standard / Agency directive]. [Gaps requiring resolution before disposition]. (Clearly separate objective findings from aeromedical interpretation. Do not declare clearance without identifying controlling standard and objective evidence of stability. Add additional problems using same structure if needed.)

Consultant Requests:

1. [Confirm diagnosis, severity/stage, and diagnostic certainty]
2. [Assess stability, prognosis, and risk of recurrence or acute events relevant to aviation duties]
3. [Comment on compatibility of current medications/treatments with safety-critical duty; recommend operationally compatible alternatives if needed]
4. [Recommend duty limitations (type and duration) and follow-up intervals]
5. [Identify additional testing required before aeromedical disposition]
6. [State whether member could be considered for clearance under applicable standard and whether waiver with limitations is indicated]

[Decision frame: Your opinion will support a determination regarding return to flight/ATC duty and whether a waiver with limitations is required.] [Requested turnaround: within [X business days]]; [Routing: secure email / secure fax / electronic portal]. (If urgent, request direct phone call.)

Interim Restrictions: [Current restrictions and start date]; [rationale]; [safety plan if symptoms recur] (Include only if interim restrictions are in place)

Attachments

• [Document type and date: clinic notes, discharge summaries, specialty consult reports, diagnostic reports, medication list, prior aeromedical decisions] (List each attachment; include prior aeromedical decisions only if consent allows)

Closing

[Brief appreciation and availability for clarifications]

[Sender name], [Credentials]
[Role], [Organization]
[Direct phone] | [Secure email]

CC: [Names/titles] (Include only if appropriate and consistent with consent/policy)