FAA Airman Medical Certificate Exam Note (Form 8500-8 Support)

Exam Date: [Date of physical examination]

Certificate Class Applied For: [First / Second / Third]

MedXPress Confirmation Number: [Confirmation number]

Identity Verification: [Type of government-issued photo ID reviewed]; name matches MedXPress application: [Yes / No] (If no, describe discrepancy and resolution.)

Application Corrections: [None / Corrections made] (If corrections made, list item numbers corrected and confirm discussion with applicant.)

Source Documents Reviewed

(List documents brought to the exam relevant to certification. For each, include type, date, source, and one-line key finding. If Special Issuance Authorization letter or SODA present, note date, condition(s) covered, and whether current requirements appear met. If documents pending, note what is expected and whether exam will be transmitted before receipt. If no outside records provided, state explicitly.)

[Document entries or "No outside records were provided"]

MedXPress History Review

(Documents AME review of applicant-entered history from FAA Form 8500-8 Items 1-20.)

Application Context: [Occupation if relevant to exposure risk]; [Airman certificate(s) held]; [Total pilot time if available]; [Prior FAA denial/suspension/revocation with dates and outcomes, or "None reported"]

Medications (Item 17a): [Reconciled medication list with name, dose, frequency, purpose, approximate start date, and side effects relevant to flight safety; or "No current medications reported"]

Medical History Positives (Item 18): (For each "Yes" response, document: condition label, onset/diagnosis date, current status, treatment history and current treatment, recent exacerbations or symptoms affecting safety, and operationally relevant negatives. For items previously reported with no change, confirm current stability.)

• [Item 18 sub-item label]: [Condition]; [Onset/diagnosis date]; [Status: active / resolved / stable]; [Treatment]; [Recent symptoms or exacerbations]; [Relevant negatives confirmed]
• (Additional entries as needed)

Healthcare Visits (Item 19): [Summary of visits relevant to certification] (For sensitive visits not relevant to aviation safety: "Reviewed with applicant; not significant or relevant to application.")

Confirmation: Items 1-20 reviewed with applicant: [Yes / No] (If no, explain what remains and next steps.)

Physical Examination (Items 21-48)

(Document each item as Normal or Abnormal with brief details for abnormalities. If exam element cannot be performed, document reason and whether deferral needed.)

Anthropometrics

• Item 21 – Height: [Value]
• Item 22 – Weight: [Value]
• Items 23-24 – SODA present: [Yes / No] (If yes: [Defect]; [SODA identifier])

Systems Examination

• Item 25 – Head, face, neck, scalp: [Normal / Abnormal]; [Details if abnormal]
• Item 26 – Nose: [Normal / Abnormal]; [Details if abnormal]
• Item 27 – Sinuses: [Normal / Abnormal]; [Details if abnormal]
• Item 28 – Mouth and throat: [Normal / Abnormal]; [Details if abnormal]
• Item 29 – Ears, general: [Normal / Abnormal]; [Details if abnormal]
• Item 30 – Eardrums: [Normal / Abnormal]; [Details if abnormal]
• Item 31 – Eyes, general: [Normal / Abnormal]; [Details if abnormal]
• Item 32 – Ophthalmoscopic: [Normal / Abnormal]; [Details if abnormal]
• Item 33 – Pupils: [Normal / Abnormal]; [Details if abnormal]
• Item 34 – Ocular motility: [Normal / Abnormal]; [Details if abnormal]
• Item 35 – Lungs and chest: [Normal / Abnormal]; [Details if abnormal]
• Item 36 – Heart: [Normal / Abnormal]; [Murmur grade, rhythm, other findings if abnormal]
• Item 37 – Vascular system: [Normal / Abnormal]; [Details if abnormal]
• Item 38 – Abdomen and viscera: [Normal / Abnormal]; [Details if abnormal]
• Item 39 – Anus: [Normal / Abnormal]; [Details if abnormal]
• Item 40 – Skin: [Normal / Abnormal]; [Details if abnormal]
• Item 41 – G-U system: [Normal / Abnormal]; [Details if abnormal]
• Item 42 – Upper and lower extremities: [Normal / Abnormal]; [Strength, ROM, measurements if abnormal]
• Item 43 – Spine and musculoskeletal: [Normal / Abnormal]; [Details if abnormal]
• Item 44 – Identifying marks, scars, tattoos: [None / Present]; [Description if present]
• Item 45 – Lymphatics: [Normal / Abnormal]; [Details if abnormal]
• Item 46 – Neurologic: [Normal / Abnormal]; [Details if abnormal]
• Item 47 – Psychiatric: [Normal / Abnormal]; [Details if abnormal]
• Item 48 – General systemic: [Normal / Abnormal]; [General impression if abnormal]

Required Tests (Items 49-58)

Item 49 – Hearing: Method: [Conversational voice at 6 feet / Audiometry]; Result: [Pass / Fail] (If non-standard pathway, describe testing sequence.)

Item 50 – Distant vision: Right: [Uncorrected] ([Corrected]); Left: [Uncorrected] ([Corrected]); Both: [Value]; Correction limitation: [Yes / No]

Item 51a – Near vision: Right: [Value]; Left: [Value]; Both: [Value]; [Corrected / Uncorrected]

Item 51b – Intermediate vision: Right: [Value]; Left: [Value]; Both: [Value]; [Corrected / Uncorrected]

Item 52 – Color vision: Test: [Test name]; Score: [Values]; Result: [Pass / Fail] (If failed, document alternative pathway and any limitation.)

Item 53 – Field of vision: [Normal / Abnormal]; [Measurements if abnormal]

Item 54 – Heterophoria: [Normal / Abnormal]; [Measurements and method if abnormal]

Item 55 – Blood pressure: [Value] (If elevated, document recheck readings with timing and deferral pathway if applicable.)

Item 56 – Pulse: [Rate and rhythm]

Item 57 – Urinalysis: [Normal / Abnormal]; [If abnormal, specify analytes and follow-up plan]

Item 58 – ECG: Required: [Yes / No based on class and age] (If obtained: Date: [Date]; Interpretation: [Summary]; Transmission status: [Transmitted / Pending])

Additional Tests and Requests (Item 59)

(Document additional tests performed, tests or records requested, with reason, source, and status.)

• [Test or record]; [Reason]; [Source]; [Status: completed / pending]; [Release obtained if applicable]
• (Additional items as needed)

Item 60 Narrative

(Structure by FAA item number. For each positive history item or abnormal finding, include: item number and problem label; timeline with onset, last episode, last treatment; severity and frequency; current status and functional impact; treatment details; objective support from exam/test findings and records; FAA relevance and applicable pathway. Use specific dates. If exceeds character limits, reference addendum with applicant name, DOB, exam date.)

• Item [##] – [Problem label]: [Timeline]; [Severity/frequency]; [Current status]; [Treatment]; [Objective findings]; [FAA pathway/relevance]
• (Additional entries as needed)
• [No significant medical history items or abnormal findings]

Certification Disposition

Disposition: [Issued / Deferred to FAA / Denied]

Rationale: [Reason for disposition]; Pathway: [Regular issuance / CACI / AASI / Special Issuance Authorization / SODA consideration]; Documentation: [Reviewed and retained / Transmitted with exam / Pending]

If Issued: Certificate class: [First / Second / Third]; Limitations: [None / List with reason]; Time limitation: [If tied to Authorization letter]

If Deferred: Missing or required items: [List]; Exam transmitted within 14-day window: [Yes / No]

If Denied: Denial letter provided to applicant: [Yes / No]; Copy sent to FAA: [Yes / No]; Basis: [Brief statement]

Follow-Up Instructions

(Include only when relevant for deferral or ongoing compliance.)

• [Next steps for applicant]
• [Safety counseling if applicable]
• [Timeline and routing for results]

Attestation

[AME attestation that examination was personally conducted, MedXPress Items 1-20 were reviewed, identity was verified, and delegated tests were supervised. This documentation supports completion and electronic transmission of FAA Form 8500-8.]